Provider Demographics
NPI:1639385289
Name:ANGELA J SANTAVICCA DDS PLLC
Entity Type:Organization
Organization Name:ANGELA J SANTAVICCA DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERGERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-643-4142
Mailing Address - Street 1:367 STATE ROUTE 120
Mailing Address - Street 2:UNIT C
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-1430
Mailing Address - Country:US
Mailing Address - Phone:603-643-4142
Mailing Address - Fax:603-643-1740
Practice Address - Street 1:367 STATE ROUTE 120
Practice Address - Street 2:UNIT C
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1430
Practice Address - Country:US
Practice Address - Phone:603-643-4142
Practice Address - Fax:603-643-1740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH26481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30310640Medicaid