Healthcare Provider Details

I. General information

NPI: 1760696595
Provider Name (Legal Business Name): ADVANTAGE DENTAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 NORWICH WESTERLY RD UNIT 2 G
NORTH STONINGTON CT
06359
US

IV. Provider business mailing address

391 NORWICH WESTERLY RD UNIT 2 G
NORTH STONINGTON CT
06359
US

V. Phone/Fax

Practice location:
  • Phone: 860-535-2331
  • Fax:
Mailing address:
  • Phone: 860-535-2331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7928
License Number StateCT

VIII. Authorized Official

Name: LINDA MROWKA III
Title or Position: OFFICE MANAGER
Credential:
Phone: 860-535-2331