Provider Demographics
NPI:1609502830
Name:MINT PREVENTATIVE DENTAL SPA, PLLC
Entity Type:Organization
Organization Name:MINT PREVENTATIVE DENTAL SPA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:IPDH
Authorized Official - Phone:603-986-3139
Mailing Address - Street 1:321 WAKEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NH
Mailing Address - Zip Code:03887-4475
Mailing Address - Country:US
Mailing Address - Phone:603-986-3139
Mailing Address - Fax:
Practice Address - Street 1:12 SULLIVAN ST
Practice Address - Street 2:SUITE 107
Practice Address - City:BERWICK
Practice Address - State:ME
Practice Address - Zip Code:03901
Practice Address - Country:US
Practice Address - Phone:603-986-3139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-29
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental