Healthcare Provider Details

I. General information

NPI: 1972912061
Provider Name (Legal Business Name): SHAO-CHING SU D.D.S., PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 08/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVENUE
FARMINGTON CT
06030
US

IV. Provider business mailing address

263 FARMINGTON AVE # MC-1725 UCONN HEALTH CENTER, SCHOOL OF DENTAL MEDICINE (L-7063)
FARMINGTON CT
06030-1725
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-2000
  • Fax:
Mailing address:
  • Phone: 860-679-2550
  • Fax: 860-679-1920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: