Healthcare Provider Details

I. General information

NPI: 1639136526
Provider Name (Legal Business Name): VINCENT NICHOLAS LAPORTA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 TOLLAND TPKE SUITE 1-C
MANCHESTER CT
06042-1771
US

IV. Provider business mailing address

360 TOLLAND TPKE SUITE 1-C
MANCHESTER CT
06042-1771
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-1429
  • Fax: 860-646-6897
Mailing address:
  • Phone: 860-646-1429
  • Fax: 860-646-6897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number9246
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2823
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDEN02823
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: