1164803037 NPI number — CONNECTICUT DENTAL PARTNERS, LLC

Table of content: (NPI 1164803037)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164803037 NPI number — CONNECTICUT DENTAL PARTNERS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONNECTICUT DENTAL PARTNERS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164803037
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 POMEROY AVE
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
MERIDEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06450-7170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-314-9493
Provider Business Mailing Address Fax Number:
203-200-7953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 POMEROY AVE
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
MERIDEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06450-7170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-314-9493
Provider Business Practice Location Address Fax Number:
203-200-7953
Provider Enumeration Date:
06/16/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BRUNELLE
Authorized Official First Name:
ROSA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
203-314-9493

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  011373 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 124Q00000X , with the licence number: 003881 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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