Provider Demographics
NPI:1831584929
Name:GREAT OUTDOORS PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:GREAT OUTDOORS PEDIATRIC DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:303-913-9951
Mailing Address - Street 1:6 OLD ROCHESTER RD
Mailing Address - Street 2:301
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-2027
Mailing Address - Country:US
Mailing Address - Phone:603-343-1228
Mailing Address - Fax:
Practice Address - Street 1:6 OLD ROCHESTER RD
Practice Address - Street 2:301
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2027
Practice Address - Country:US
Practice Address - Phone:603-343-1228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH040931223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty