Healthcare Provider Details

I. General information

NPI: 1154443729
Provider Name (Legal Business Name): GRISELDA G KHOE DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 N MAIN ST
SOUTHINGTON CT
06489-2517
US

IV. Provider business mailing address

76 N MAIN ST
SOUTHINGTON CT
06489-2517
US

V. Phone/Fax

Practice location:
  • Phone: 860-628-8868
  • Fax:
Mailing address:
  • Phone: 860-628-8868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7570
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: