Healthcare Provider Details

I. General information

NPI: 1023446093
Provider Name (Legal Business Name): LIFE LONG DENTAL CARE OF NORTHFORD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 MIDDLETOWN AVE
NORTHFORD CT
06472-1382
US

IV. Provider business mailing address

1355 MIDDLETOWN AVE
NORTHFORD CT
06472-1382
US

V. Phone/Fax

Practice location:
  • Phone: 203-484-0456
  • Fax: 203-484-4050
Mailing address:
  • Phone: 203-484-0456
  • Fax: 203-484-4050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JEREMIAH LONG
Title or Position: OWNER
Credential: D.M.D.
Phone: 203-484-0456