Healthcare Provider Details

I. General information

NPI: 1265942676
Provider Name (Legal Business Name): ADVANCED DENTAL OF CROMWELL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 SHUNPIKE RD STE A
CROMWELL CT
06416-2442
US

IV. Provider business mailing address

26 SHUNPIKE RD STE A
CROMWELL CT
06416-2442
US

V. Phone/Fax

Practice location:
  • Phone: 860-894-2933
  • Fax: 860-828-1610
Mailing address:
  • Phone: 860-894-2933
  • Fax: 860-828-1610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberCT006968
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL MAROON
Title or Position: MANAGING MEMBER/OWNER
Credential: DMD
Phone: 860-894-2933