Healthcare Provider Details

I. General information

NPI: 1285002063
Provider Name (Legal Business Name): DANIEL M SEGAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2015
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 SULLIVAN AVE
SOUTH WINDSOR CT
06074-2000
US

IV. Provider business mailing address

1050 SULLIVAN AVE
SOUTH WINDSOR CT
06074-2000
US

V. Phone/Fax

Practice location:
  • Phone: 860-644-2476
  • Fax: 860-644-1175
Mailing address:
  • Phone: 860-644-2476
  • Fax: 860-644-1175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5000
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIEL SEGAL
Title or Position: OWNER
Credential: DMD
Phone: 860-644-2476