Healthcare Provider Details

I. General information

NPI: 1659682979
Provider Name (Legal Business Name): NATHAN ELDON MUMFORD D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 06/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

291 FARMINGTON AVE
FARMINGTON CT
06032-1925
US

IV. Provider business mailing address

400 BLAKE ST APT 2408
NEW HAVEN CT
06515-4412
US

V. Phone/Fax

Practice location:
  • Phone: 860-677-8666
  • Fax: 860-677-5893
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10532
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: