Healthcare Provider Details

I. General information

NPI: 1043696107
Provider Name (Legal Business Name): WALNUT DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 FRANKLIN AVE
HARTFORD CT
06114
US

IV. Provider business mailing address

297 UNION AVE
FRAMINGHAM MA
01702
US

V. Phone/Fax

Practice location:
  • Phone: 860-296-5437
  • Fax:
Mailing address:
  • Phone: 508-879-0270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State

VIII. Authorized Official

Name: MRS. LISA CHOINEIRE
Title or Position: BILLING MANAGER
Credential:
Phone: 508-879-0270