Healthcare Provider Details

I. General information

NPI: 1386035707
Provider Name (Legal Business Name): MODERN FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 BOSTON AVE SUITE 17
STRATFORD CT
06614-5213
US

IV. Provider business mailing address

320 BOSTON AVE SUITE 17
STRATFORD CT
06614-5213
US

V. Phone/Fax

Practice location:
  • Phone: 860-437-3462
  • Fax: 860-437-3485
Mailing address:
  • Phone: 860-437-3462
  • Fax: 860-437-3485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateCT

VIII. Authorized Official

Name: MRS. LINDA MROWKA
Title or Position: OFFICE MANAGER
Credential:
Phone: 860-437-3462