Provider Demographics
NPI:1679640130
Name:CHAPUT, MARTIN LEO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:LEO
Last Name:CHAPUT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 PEQUAWKET TRL
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:NH
Mailing Address - Zip Code:03836-4435
Mailing Address - Country:US
Mailing Address - Phone:603-539-6670
Mailing Address - Fax:
Practice Address - Street 1:298 WHITE MOUNTAIN HWY
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03818-4204
Practice Address - Country:US
Practice Address - Phone:603-447-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH03517122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH03517OtherDELTA DENTAL
NH30304433Medicaid