Healthcare Provider Details

I. General information

NPI: 1376663609
Provider Name (Legal Business Name): AVON VILLAGE FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 EAST MAIN STREET
AVON CT
06001-1039
US

IV. Provider business mailing address

32 EAST MAIN STREET
AVON CT
06001-1039
US

V. Phone/Fax

Practice location:
  • Phone: 860-678-1140
  • Fax: 860-284-4423
Mailing address:
  • Phone: 860-678-1140
  • Fax: 860-284-4423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MS. LAUREN M MENTASTI
Title or Position: OWNER
Credential: DMD
Phone: 860-678-1140