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General NPI Number Information
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NPI Number | 1194431056
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Entity Type | Organization
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Legal Business Name | CLOVER DENTAL CARE LLC
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Dates
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Enumeration Date | 01/24/2023
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Last Update Date | 01/30/2023
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Provider Practice Location Address
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Address Line | 1209 S BROAD ST
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City | WALLINGFORD
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State | CT
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Zip | 06492-1714
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Country | US
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Telephone | 203-934-3400
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Fax |
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Provider Business Mailing Address
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Address Line | 1209 S BROAD ST
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City | WALLINGFORD
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State | CT
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Zip | 06492-1714
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Country | US
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Telephone | 203-934-3400
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | RYAN KU
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Credential |
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Telephone | 713-591-5434
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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 |
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License Number State |
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