Provider Demographics
NPI:1700042173
Name:EDWARD J DETOLLA DDS PLLC
Entity Type:Organization
Organization Name:EDWARD J DETOLLA DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DETOLLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PLLC
Authorized Official - Phone:603-279-8200
Mailing Address - Street 1:146 NH ROUTE 25
Mailing Address - Street 2:
Mailing Address - City:MEREDITH
Mailing Address - State:NH
Mailing Address - Zip Code:03253
Mailing Address - Country:US
Mailing Address - Phone:603-279-8200
Mailing Address - Fax:603-279-8200
Practice Address - Street 1:146 NH ROUTE 25
Practice Address - Street 2:
Practice Address - City:MEREDITH
Practice Address - State:NH
Practice Address - Zip Code:03253
Practice Address - Country:US
Practice Address - Phone:603-279-8200
Practice Address - Fax:603-279-8200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3767122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty