Healthcare Provider Details

I. General information

NPI: 1679491294
Provider Name (Legal Business Name): KAJONWUD SHANE CHONGULIA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WAHOO AVE
GROTON CT
06349-2324
US

IV. Provider business mailing address

PO BOX 600
GROTON CT
06349-5600
US

V. Phone/Fax

Practice location:
  • Phone: 860-694-3736
  • Fax:
Mailing address:
  • Phone: 860-694-3736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI03172600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: