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General NPI Number Information
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NPI Number | 1174814495
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Entity Type | Organization
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Legal Business Name | BLUE BACK DENTAL LLC
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Dates
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Enumeration Date | 04/20/2011
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Last Update Date | 04/20/2011
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Provider Practice Location Address
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Address Line | 65 MEMORIAL RD STE 400
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City | WEST HARTFORD
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State | CT
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Zip | 06107-4219
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Country | US
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Telephone | 860-233-9300
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Fax | 860-233-9304
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Provider Business Mailing Address
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Address Line | 65 MEMORIAL RD STE 400
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City | WEST HARTFORD
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State | CT
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Zip | 06107-4219
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Country | US
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Telephone | 860-233-9300
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Fax | 860-233-9304
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | KIRSTEN E CAPOZZI
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Credential |
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Telephone | 860-233-9300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 8915
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 5407
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License Number State | CT
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 5904
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License Number State | CT
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