1639555451 NPI number — REIDVILLE DENTISTRY & IMPLANTS

Table of content: (NPI 1639555451)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639555451 NPI number — REIDVILLE DENTISTRY & IMPLANTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REIDVILLE DENTISTRY & IMPLANTS
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:
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:
1639555451
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
48 OCEAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW LONDON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06320-3414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-444-9345
Provider Business Mailing Address Fax Number:
860-437-1938

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
464 REIDVILLE DR
Provider Second Line Business Practice Location Address:
SUITE A2
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06705-2650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-444-9345
Provider Business Practice Location Address Fax Number:
860-437-1938
Provider Enumeration Date:
08/04/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SANTA MARIA
Authorized Official First Name:
ANGELINA
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
860-997-0569

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com