Healthcare Provider Details

I. General information

NPI: 1942104435
Provider Name (Legal Business Name): SOUTHBURY DENTISTRY & IMPLANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 MAIN ST S STE M
SOUTHBURY CT
06488-2263
US

IV. Provider business mailing address

250 MAIN ST S STE M
SOUTHBURY CT
06488-2263
US

V. Phone/Fax

Practice location:
  • Phone: 203-264-9606
  • Fax:
Mailing address:
  • Phone: 203-264-9606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANGELINA BLANKSCHEN
Title or Position: CFO
Credential:
Phone: 860-997-0569