Healthcare Provider Details

I. General information

NPI: 1265620082
Provider Name (Legal Business Name): HARTFORD SMILES YOUTH DENTISTRY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 07/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 FRANKLIN AVE
HARTFORD CT
06114-1848
US

IV. Provider business mailing address

16 ARCADE UNIT 198747
NASHVILLE TN
37219-1994
US

V. Phone/Fax

Practice location:
  • Phone: 860-296-5437
  • Fax: 860-296-5454
Mailing address:
  • Phone: 615-750-0343
  • Fax: 615-986-1705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. JENELL STUMP
Title or Position: MANAGER, LICENSING & CREDENTIALING
Credential:
Phone: 615-750-0343