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General NPI Number Information
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NPI Number | 1013629369
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Entity Type | Organization
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Legal Business Name | ST. BERNARD DENTISTRY PLLC
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Dates
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Enumeration Date | 12/19/2022
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Last Update Date | 12/19/2022
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Provider Practice Location Address
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Address Line | 697 POQUONOCK AVE UNIT 7
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City | WINDSOR
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State | CT
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Zip | 06095-2249
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Country | US
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Telephone | 860-219-0933
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Fax |
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Provider Business Mailing Address
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Address Line | 28 BRIGHTON DR
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City | EAST GRANBY
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State | CT
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Zip | 06026-9423
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Country | US
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Telephone | 860-751-2470
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Fax |
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Authorized Official
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Title or Position | MEMBER /OWNER
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Name | DR. LISA ST. BERNARD
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Credential | DMD
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Telephone | 860-751-2470
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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