Provider Demographics
NPI:1770817645
Name:MY DENTIST
Entity Type:Organization
Organization Name:MY DENTIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:KREFTING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:603-965-3407
Mailing Address - Street 1:25 BUTTRICK RD
Mailing Address - Street 2:
Mailing Address - City:LONDONDERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03053-3341
Mailing Address - Country:US
Mailing Address - Phone:603-965-3407
Mailing Address - Fax:
Practice Address - Street 1:25 BUTTRICK RD
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:NH
Practice Address - Zip Code:03053-3341
Practice Address - Country:US
Practice Address - Phone:603-965-3407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH03715122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA264370191OtherBLUE CROSS BLUE SHIELD