Healthcare Provider Details

I. General information

NPI: 1134512932
Provider Name (Legal Business Name): LRD DANBURY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 GLEN HILL RD
DANBURY CT
06811-4906
US

IV. Provider business mailing address

2 GLEN HILL RD
DANBURY CT
06811-4906
US

V. Phone/Fax

Practice location:
  • Phone: 203-797-9392
  • Fax: 203-797-9588
Mailing address:
  • Phone: 203-797-9392
  • Fax: 203-797-9588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10227
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10227
License Number StateCT

VIII. Authorized Official

Name: DR. JUSTINA CHO
Title or Position: OWNER
Credential:
Phone: 646-369-6918