Healthcare Provider Details

I. General information

NPI: 1225028657
Provider Name (Legal Business Name): CHILDREN'S DENTAL ASSOCIATES OF NLC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

392 SALEM TPKE
BOZRAH CT
06334-1519
US

IV. Provider business mailing address

392 SALEM TPKE
BOZRAH CT
06334-1519
US

V. Phone/Fax

Practice location:
  • Phone: 860-886-5576
  • Fax: 860-885-1379
Mailing address:
  • Phone: 860-886-5576
  • Fax: 860-885-1379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. MICHELLE S HERTER
Title or Position: MANGER
Credential:
Phone: 860-886-5576