Provider Demographics
NPI:1285935866
Name:CHILDREN'S DENTISTRY OF THE LAKES REGION, PLLC
Entity type:Organization
Organization Name:CHILDREN'S DENTISTRY OF THE LAKES REGION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:KENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:603-527-2500
Mailing Address - Street 1:369 HOUNSELL AVE
Mailing Address - Street 2:UNIT #1
Mailing Address - City:GILFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03249
Mailing Address - Country:US
Mailing Address - Phone:603-527-2500
Mailing Address - Fax:
Practice Address - Street 1:369 HOUNSELL AVE
Practice Address - Street 2:UNIT #1
Practice Address - City:GILFORD
Practice Address - State:NH
Practice Address - Zip Code:03249
Practice Address - Country:US
Practice Address - Phone:603-527-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH03570122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty