Healthcare Provider Details

I. General information

NPI: 1104833862
Provider Name (Legal Business Name): HEALTHY SMILES DENTAL CARE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MAIN ST STE 17
WINDSOR LOCKS CT
06096-2345
US

IV. Provider business mailing address

2O MAIN ST STE 17
WINDSOR LOCKS CT
06096-1916
US

V. Phone/Fax

Practice location:
  • Phone: 860-623-2601
  • Fax: 860-370-5467
Mailing address:
  • Phone: 860-623-2601
  • Fax: 860-370-5467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number009404
License Number StateCT

VIII. Authorized Official

Name: DR. CHUNG KIM
Title or Position: PRESIDENT
Credential: DMD
Phone: 860-623-2601