Healthcare Provider Details

I. General information

NPI: 1437766276
Provider Name (Legal Business Name): MICHAEL DENTAL OF CLINTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 COMMERCE ST
CLINTON CT
06413-2054
US

IV. Provider business mailing address

37 COMMERCE ST
CLINTON CT
06413-2054
US

V. Phone/Fax

Practice location:
  • Phone: 860-669-5777
  • Fax:
Mailing address:
  • Phone: 860-669-5777
  • Fax:

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 Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. STACEY MICHAEL
Title or Position: OWNER DENTIST
Credential: DMD
Phone: 860-669-5777