Healthcare Provider Details

I. General information

NPI: 1235478686
Provider Name (Legal Business Name): R.E. HOLDINGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 12/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 WOLCOTT ST
WATERBURY CT
06705-1315
US

IV. Provider business mailing address

835 WOLCOTT ST
WATERBURY CT
06705-1315
US

V. Phone/Fax

Practice location:
  • Phone: 203-596-1960
  • Fax: 203-596-1998
Mailing address:
  • Phone: 203-596-1960
  • Fax: 203-596-1998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number007375
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number010946
License Number StateCT

VIII. Authorized Official

Name: DR. LON POLVERARI
Title or Position: OWNER
Credential: DMD
Phone: 917-656-0798