Healthcare Provider Details

I. General information

NPI: 1871974014
Provider Name (Legal Business Name): MBRACES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 06/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 CENTER ST
BRISTOL CT
06010-4916
US

IV. Provider business mailing address

5 CENTER ST
BRISTOL CT
06010-4916
US

V. Phone/Fax

Practice location:
  • Phone: 860-589-3316
  • Fax:
Mailing address:
  • Phone: 860-589-3316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number011110
License Number StateCT

VIII. Authorized Official

Name: DR. PRADIPTA MAZUMDER
Title or Position: ORTHODONTIST
Credential: D.D.S.
Phone: 571-594-6007