Healthcare Provider Details

I. General information

NPI: 1568603934
Provider Name (Legal Business Name): WOLCOTT STREET DENTAL-1, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2009
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 ELM ST
NEW HAVEN CT
06511-4549
US

IV. Provider business mailing address

210 INTERSTATE NORTH PKWY SE STE 300
ATLANTA GA
30339-2233
US

V. Phone/Fax

Practice location:
  • Phone: 770-916-5028
  • Fax: 678-247-7858
Mailing address:
  • Phone: 770-916-5028
  • Fax: 678-247-7858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE JACOMINO
Title or Position: DIRECTOR OF PAYOR RELATIONS
Credential:
Phone: 770-916-5036