Provider Demographics
NPI:1336556554
Name:WELLSPRING DENTAL OF BEDFORD, LLC
Entity Type:Organization
Organization Name:WELLSPRING DENTAL OF BEDFORD, LLC
Other - Org Name:WELLSPRING DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:603-232-5490
Mailing Address - Street 1:169 S RIVER RD
Mailing Address - Street 2:STE 6
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6971
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:169 S RIVER RD
Practice Address - Street 2:STE 6
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6971
Practice Address - Country:US
Practice Address - Phone:603-232-5490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH03777122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty