Healthcare Provider Details

I. General information

NPI: 1215149596
Provider Name (Legal Business Name): PETER PETERSON & JESSE SORRENTINO P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

291 FARMINGTON AVE
FARMINGTON CT
06032-1925
US

IV. Provider business mailing address

291 FARMINGTON AVE
FARMINGTON CT
06032-1925
US

V. Phone/Fax

Practice location:
  • Phone: 860-677-8747
  • Fax: 860-674-9670
Mailing address:
  • Phone: 860-677-8747
  • Fax: 860-674-9670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number7255
License Number StateCT

VIII. Authorized Official

Name: JESSE M SORRENTINO
Title or Position: PARTNER
Credential: DDS
Phone: 860-677-8747