Healthcare Provider Details

I. General information

NPI: 1114234697
Provider Name (Legal Business Name): NUTMEG DENTAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2010
Last Update Date: 09/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1266 E MAIN ST STE 700R
STAMFORD CT
06902-3550
US

IV. Provider business mailing address

1266 EAST MAIN STREET, SUITE 700R
STAMFORD CT
06902
US

V. Phone/Fax

Practice location:
  • Phone: 888-833-8441
  • Fax: 888-330-4331
Mailing address:
  • Phone: 888-833-8441
  • Fax: 888-330-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number005405
License Number StateCT

VIII. Authorized Official

Name: RONALD J. LINDEN
Title or Position: DENTAL DIRECTOR
Credential: DDS
Phone: 888-833-8441