Healthcare Provider Details

I. General information

NPI: 1912394834
Provider Name (Legal Business Name): CONNECTICUT SMILES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2015
Last Update Date: 04/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 WATERTOWN AVE STE 1
WATERBURY CT
06708-2623
US

IV. Provider business mailing address

427 STILLSON RD STE 12
FAIRFIELD CT
06824-3158
US

V. Phone/Fax

Practice location:
  • Phone: 203-754-7100
  • Fax:
Mailing address:
  • Phone: 203-374-0512
  • Fax: 203-372-0280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number005825
License Number StateCT

VIII. Authorized Official

Name: THOMAS BRAUN
Title or Position: MANAGER
Credential:
Phone: 203-754-7100