Healthcare Provider Details

I. General information

NPI: 1114331931
Provider Name (Legal Business Name): SHORELINE CHILDRENS DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

934 BOSTON POST RD SUITE 3-A
GUILFORD CT
06437-2713
US

IV. Provider business mailing address

934 BOSTON POST RD SUITE 3-A
GUILFORD CT
06437-2713
US

V. Phone/Fax

Practice location:
  • Phone: 860-575-0594
  • Fax: 860-349-1481
Mailing address:
  • Phone: 860-575-0594
  • Fax: 860-349-1481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number009873
License Number StateCT

VIII. Authorized Official

Name: DR. KATHRYN MARGARET GLAZER
Title or Position: MEMBER
Credential: D.M.D.
Phone: 860-575-0594