Healthcare Provider Details

I. General information

NPI: 1497553150
Provider Name (Legal Business Name): CONNECTICUT EAST DENTAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2025
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 HARTFORD TPKE STE 210
VERNON CT
06066-4759
US

IV. Provider business mailing address

281 HARTFORD TPKE STE 210
VERNON CT
06066-4759
US

V. Phone/Fax

Practice location:
  • Phone: 860-875-5989
  • Fax:
Mailing address:
  • Phone: 860-875-5989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BARBARA J KHAN
Title or Position: BUSINESS MANAGER
Credential:
Phone: 860-875-5989