Provider Demographics
NPI:1861457665
Name:GRACE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:GRACE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCCULLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:603-225-6650
Mailing Address - Street 1:143 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301
Mailing Address - Country:US
Mailing Address - Phone:603-225-6650
Mailing Address - Fax:603-225-9495
Practice Address - Street 1:143 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301
Practice Address - Country:US
Practice Address - Phone:603-225-6650
Practice Address - Fax:603-225-9495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1604122300000X
NH3170122300000X
NH2389122300000X
NH1478122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30004745Medicaid
NH0206510Y0NH01OtherBLUE CROSS FEDERAL