Provider Demographics
NPI:1780094763
Name:DOVER PEDIATRIC DENTISTRY & ORTHODONTICS PLLC
Entity type:Organization
Organization Name:DOVER PEDIATRIC DENTISTRY & ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR / DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:DON
Authorized Official - Last Name:WENDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:603-686-3928
Mailing Address - Street 1:750 CENTRAL AVE
Mailing Address - Street 2:SUITE K
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-3434
Mailing Address - Country:US
Mailing Address - Phone:603-743-6000
Mailing Address - Fax:
Practice Address - Street 1:750 CENTRAL AVE
Practice Address - Street 2:SUITE K
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-3434
Practice Address - Country:US
Practice Address - Phone:603-743-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH31341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3081208Medicaid