Provider Demographics
NPI:1861853095
Name:WOLFEBORO FAMILY DENTAL, PLLC
Entity Type:Organization
Organization Name:WOLFEBORO FAMILY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ELLINGWOOD
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:603-569-2268
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:WOLFEBORO FALLS
Mailing Address - State:NH
Mailing Address - Zip Code:03896-0098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 VARNEY RD
Practice Address - Street 2:
Practice Address - City:WOLFEBORO
Practice Address - State:NH
Practice Address - Zip Code:03894
Practice Address - Country:US
Practice Address - Phone:603-569-2268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH042081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty