Healthcare Provider Details

I. General information

NPI: 1518256643
Provider Name (Legal Business Name): HARTFORD COSMETIC DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 FARMINGTON AVE # LL2
HARTFORD CT
06105-3081
US

IV. Provider business mailing address

609 FARMINGTON AVE # LL2
HARTFORD CT
06105-3081
US

V. Phone/Fax

Practice location:
  • Phone: 860-206-9641
  • Fax:
Mailing address:
  • Phone: 860-206-9641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10110
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number10004
License Number StateCT

VIII. Authorized Official

Name: CHIA HUI JENNY KWON
Title or Position: DENTIST/PART OWNER OF THE OFFICE
Credential:
Phone: 917-453-4055