Healthcare Provider Details

I. General information

NPI: 1275934051
Provider Name (Legal Business Name): WESTERN CONNECTICUT DENTAL ARTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2014
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PARK LANE RD UNIT B201
NEW MILFORD CT
06776-2444
US

IV. Provider business mailing address

120 PARK LANE RD UNIT B201
NEW MILFORD CT
06776-2444
US

V. Phone/Fax

Practice location:
  • Phone: 860-350-9232
  • Fax: 860-355-9232
Mailing address:
  • Phone: 860-350-9232
  • Fax: 860-355-9232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number009825
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number006219
License Number StateCT

VIII. Authorized Official

Name: DR. KEVIN M STANTON
Title or Position: OWNER
Credential: DMD
Phone: 860-350-9232