Healthcare Provider Details

I. General information

NPI: 1295995371
Provider Name (Legal Business Name): TAKANORI SOBUE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-1710
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06032-1956
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-2000
  • Fax:
Mailing address:
  • Phone: 860-679-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number010364
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: