Healthcare Provider Details

I. General information

NPI: 1164564761
Provider Name (Legal Business Name): SUFFIELD VILLAGE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 SUFFIELD VLG
SUFFIELD CT
06078-2122
US

IV. Provider business mailing address

215 SUFFIELD VLG
SUFFIELD CT
06078-2122
US

V. Phone/Fax

Practice location:
  • Phone: 860-668-4431
  • Fax:
Mailing address:
  • Phone: 860-668-4431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4137
License Number StateCT

VIII. Authorized Official

Name: DR. LAWRENCE ALBERT
Title or Position: PRESIDENT
Credential: DDS
Phone: 860-668-4431