Healthcare Provider Details

I. General information

NPI: 1699113647
Provider Name (Legal Business Name): SHRADDHA ANDRE MARSHALL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHRADDHA VILAS POWAR DDS

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 09/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06032-1956
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06032-1956
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-2505
  • Fax:
Mailing address:
  • Phone: 860-679-2505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2.011438 PROV
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11438
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: