Provider Demographics
NPI:1912312190
Name:JASON J PEACOCK DDS, MS, PLLC
Entity Type:Organization
Organization Name:JASON J PEACOCK DDS, MS, PLLC
Other - Org Name:RIVERVIEW DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:J
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:603-228-1066
Mailing Address - Street 1:6 LOUDON RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-5345
Mailing Address - Country:US
Mailing Address - Phone:603-228-1066
Mailing Address - Fax:603-228-5305
Practice Address - Street 1:6 LOUDON RD
Practice Address - Street 2:SUITE 202
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-5345
Practice Address - Country:US
Practice Address - Phone:603-228-1066
Practice Address - Fax:603-228-5305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH03968122300000X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3081496Medicaid