Healthcare Provider Details

I. General information

NPI: 1720083934
Provider Name (Legal Business Name): WATERFORD DENTAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 HARTFORD TPKE
WATERFORD CT
06385-4201
US

IV. Provider business mailing address

815 HARTFORD TPKE
WATERFORD CT
06385-4201
US

V. Phone/Fax

Practice location:
  • Phone: 860-444-0625
  • Fax: 860-442-7740
Mailing address:
  • Phone: 860-444-0625
  • Fax: 860-442-7740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: DR. VINCENT S CIANCIULLI
Title or Position: PRESIDENT
Credential: DMD
Phone: 860-444-0625