Healthcare Provider Details

I. General information

NPI: 1790920213
Provider Name (Legal Business Name): RONALD D. KIRSCHBAUM DMD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2008
Last Update Date: 12/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230A MOUNTAIN RD
SUFFIELD CT
06078-2082
US

IV. Provider business mailing address

230A MOUNTAIN RD
SUFFIELD CT
06078-2082
US

V. Phone/Fax

Practice location:
  • Phone: 860-668-6128
  • Fax: 860-386-6736
Mailing address:
  • Phone: 860-668-6128
  • Fax: 860-386-6736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7283
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7282
License Number StateCT

VIII. Authorized Official

Name: DR. RONALD D KIRSCHBAUM
Title or Position: OWNER
Credential: DMD
Phone: 860-668-6128