Healthcare Provider Details

I. General information

NPI: 1730644212
Provider Name (Legal Business Name): RESOLUTE CROSS ROAD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2019
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 CROSS RD
WATERFORD CT
06385-1204
US

IV. Provider business mailing address

112 CROSS RD
WATERFORD CT
06385-1204
US

V. Phone/Fax

Practice location:
  • Phone: 860-447-1787
  • Fax:
Mailing address:
  • Phone: 860-447-1787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GREGORY A TOBACK
Title or Position: OWNER
Credential: DMD, MS
Phone: 860-443-2428