Healthcare Provider Details

I. General information

NPI: 1164803037
Provider Name (Legal Business Name): CONNECTICUT DENTAL PARTNERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 POMEROY AVE SUITE 205
MERIDEN CT
06450-7170
US

IV. Provider business mailing address

240 POMEROY AVE SUITE 205
MERIDEN CT
06450-7170
US

V. Phone/Fax

Practice location:
  • Phone: 203-314-9493
  • Fax: 203-200-7953
Mailing address:
  • Phone: 203-314-9493
  • Fax: 203-200-7953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number011373
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number003881
License Number StateCT

VIII. Authorized Official

Name: MRS. ROSA BRUNELLE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 203-314-9493