MEDICARE: WEST HARTFORD FAMILY DENTISTRY

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		CT

General Provider Information

NPI Number	:	1487838330
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST HARTFORD FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	342 N MAIN ST
Second Line	:	SUITE # 300
City	:	WEST HARTFORD
State	:	CT
Zip	:	06117-2500
Country	:	US
Telephone Number	:	860-233-0552
Fax Number	:	860-233-9614

Provider Business Practice Location Address
First Line	:	342 N MAIN ST
Second Line	:	SUITE # 300
City	:	WEST HARTFORD
State	:	CT
Zip	:	06117-2500
Country	:	US
Telephone Number	:	860-233-0552
Fax Number	:	860-233-9614

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROY W. SHAKUN
Credential	:	D.M.D.
Telephone Number	:	860-233-0552

Provider Enumeration Date	:	12/27/2007
Last Update Date	:	12/27/2007

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