Provider Demographics
NPI:1598058968
Name:MANCHESTER WALK IN DENTAL CLINIC PC
Entity Type:Organization
Organization Name:MANCHESTER WALK IN DENTAL CLINIC PC
Other - Org Name:NH WALK IN DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIAA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MAHABA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:603-703-0220
Mailing Address - Street 1:25 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-5738
Mailing Address - Country:US
Mailing Address - Phone:603-703-0220
Mailing Address - Fax:603-703-0221
Practice Address - Street 1:25 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-5738
Practice Address - Country:US
Practice Address - Phone:603-703-0220
Practice Address - Fax:603-703-0221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH038241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty