Healthcare Provider Details

I. General information

NPI: 1881893717
Provider Name (Legal Business Name): DANIEL JOHN GILL D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 01/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 DALE RD SUITE 105
AVON CT
06001-3659
US

IV. Provider business mailing address

22 RAVENWOOD RD
WEST HARTFORD CT
06107-1538
US

V. Phone/Fax

Practice location:
  • Phone: 860-674-8079
  • Fax: 860-676-8242
Mailing address:
  • Phone: 860-904-5520
  • Fax: 860-676-8242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number010169
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number052166
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: