Healthcare Provider Details

I. General information

NPI: 1407572605
Provider Name (Legal Business Name): NEW ENGLAND ENDODONTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 TOLLAND TPKE STE 2A
MANCHESTER CT
06042-1770
US

IV. Provider business mailing address

66 DWIGHT RD STE 4
LONGMEADOW MA
01106-1949
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-4811
  • Fax:
Mailing address:
  • Phone: 413-565-2733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: LEAH ANN MAYLOTT
Title or Position: CREDENTIALING ADMINISTRATOR
Credential:
Phone: 860-874-8198