Healthcare Provider Details

I. General information

NPI: 1225399108
Provider Name (Legal Business Name): ENDODONTIC SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CHUCRH ST # 670
ELLINGTON CT
06029-0670
US

IV. Provider business mailing address

PO BOX 670
ELLINGTON CT
06029-0670
US

V. Phone/Fax

Practice location:
  • Phone: 860-000-0000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number9473
License Number StateCT

VIII. Authorized Official

Name: DR. STANISLAV MOLINE
Title or Position: MANAGER
Credential: DMD, MDS
Phone: 860-000-0000