Healthcare Provider Details

I. General information

NPI: 1881987964
Provider Name (Legal Business Name): CT DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2011
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 GRANDVIEW AVE SUITE 103
WATERBURY CT
06708-2517
US

IV. Provider business mailing address

171 GRANDVIEW AVE SUITE 103
WATERBURY CT
06708-2517
US

V. Phone/Fax

Practice location:
  • Phone: 203-574-2725
  • Fax: 203-574-2726
Mailing address:
  • Phone: 203-574-2725
  • Fax: 203-574-2726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number010282
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateCT

VIII. Authorized Official

Name: DR. TULASI N VIKRAM
Title or Position: OWNER
Credential: DDS
Phone: 203-574-2725