Healthcare Provider Details

I. General information

NPI: 1962624890
Provider Name (Legal Business Name): RODERICK LAMONT MACNEIL D.D.S., M.DENT.SC.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVENUE UNIVERSITY DENTISTS
FARMINGTON CT
06030
US

IV. Provider business mailing address

263 FARMINGTON AVENUE UNIVERSITY DENTISTS
FARMINGTON CT
06030-2820
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-3170
  • Fax: 860-679-8162
Mailing address:
  • Phone: 860-679-3170
  • Fax: 860-679-8162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number008549
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: