Healthcare Provider Details

I. General information

NPI: 1134321318
Provider Name (Legal Business Name): KANDASAMY RENGASAMY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVENUE UCONN SCHOOL OF DENTAL MEDICINE
FARMINGTON CT
06030-2105
US

IV. Provider business mailing address

263 FARMINGTON AVENUE UCONN SCHOOL OF DENTAL MEDICINE
FARMINGTON CT
06030-2105
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-2476
  • Fax:
Mailing address:
  • Phone: 860-679-2207
  • Fax: 860-679-1899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number010435
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: