Healthcare Provider Details

I. General information

NPI: 1013318963
Provider Name (Legal Business Name): WALNUT DENTAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2014
Last Update Date: 11/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 FRANKLIN AVE
HARTFORD CT
06114-1848
US

IV. Provider business mailing address

297 UNION AVE
FRAMINGHAM MA
01702-6337
US

V. Phone/Fax

Practice location:
  • Phone: 860-296-5437
  • Fax:
Mailing address:
  • Phone: 978-580-1524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JOANNE TAVANO
Title or Position: DIRECTOR
Credential:
Phone: 978-580-1524