Healthcare Provider Details

I. General information

NPI: 1013393578
Provider Name (Legal Business Name): SPH MERIDEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 08/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 LEWIS AVE
MERIDEN CT
06451-2103
US

IV. Provider business mailing address

470 LEWIS AVE
MERIDEN CT
06451-2103
US

V. Phone/Fax

Practice location:
  • Phone: 203-440-4199
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MR. ANDRE LAVOIE
Title or Position: OFFICE MANAGER
Credential:
Phone: 860-644-0099