Provider Demographics
NPI:1295956944
Name:CHESTNUT FAMILY DENTAL, LLC
Entity type:Organization
Organization Name:CHESTNUT FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:KENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-622-7173
Mailing Address - Street 1:745 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-3002
Mailing Address - Country:US
Mailing Address - Phone:603-622-7173
Mailing Address - Fax:603-668-2709
Practice Address - Street 1:745 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-3002
Practice Address - Country:US
Practice Address - Phone:603-622-7173
Practice Address - Fax:603-668-2709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3178261QD0000X
NH3147261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30303489Medicaid
NH30301213Medicaid