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General NPI Number Information
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NPI Number | 1093153918
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Entity Type | Organization
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Legal Business Name | CANDLEWOOD FAMILY DENTAL LLC
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Dates
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Enumeration Date | 06/13/2013
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Last Update Date | 06/13/2013
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Provider Practice Location Address
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Address Line | 940 FEDERAL RD
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City | BROOKFIELD
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State | CT
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Zip | 06804-1150
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Country | US
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Telephone | 203-775-5533
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Fax | 203-775-5511
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Provider Business Mailing Address
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Address Line | 940 FEDERAL RD
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City | BROOKFIELD
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State | CT
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Zip | 06804-1150
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Country | US
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Telephone | 203-775-5533
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Fax | 203-775-5511
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Authorized Official
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Title or Position | MEMBER
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Name | CHRISTINE R WALDRON
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Credential | DDS
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Telephone | 203-775-5533
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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 | 009332
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License Number State | CT
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