MEDICARE: BRIAN HILTON ODLUM D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4017	CT

General Provider Information

NPI Number	:	1073668349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN HILTON ODLUM D.M.D.

Provider Business Mailing Address
First Line	:	7 S MAIN ST
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06107-2447
Country	:	US
Telephone Number	:	860-523-0721
Fax Number	:	860-232-5171

Provider Business Practice Location Address
First Line	:	7 S MAIN ST
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06107-2447
Country	:	US
Telephone Number	:	860-523-0721
Fax Number	:	860-232-5171

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	07/08/2007

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