Provider Demographics
NPI:1528480902
Name:CONWAY VILLAGE DENTAL
Entity type:Organization
Organization Name:CONWAY VILLAGE DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DUDEVOIR-BADGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:603-447-6707
Mailing Address - Street 1:21A POLIQUIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03818
Mailing Address - Country:US
Mailing Address - Phone:603-447-6707
Mailing Address - Fax:603-447-8376
Practice Address - Street 1:21A POLIQUIN DRIVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03818
Practice Address - Country:US
Practice Address - Phone:603-447-6707
Practice Address - Fax:603-447-8376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3080677Medicaid