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General NPI Number Information
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NPI Number | 1225508526
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Entity Type | Organization
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Legal Business Name | CENTRAL CONNECTICUT OROFACIAL SLEEP MEDICINE INC
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Dates
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Enumeration Date | 11/29/2018
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Last Update Date | 11/29/2018
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Provider Practice Location Address
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Address Line | 55 NYE RD STE 101
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City | GLASTONBURY
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State | CT
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Zip | 06033-1281
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Country | US
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Telephone | 860-430-5687
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Fax |
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Provider Business Mailing Address
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Address Line | 55 NYE RD STE 101
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City | GLASTONBURY
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State | CT
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Zip | 06033-1281
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Country | US
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Telephone | 860-430-5687
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Fax |
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | RAQUEL FONTAINE
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Credential |
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Telephone | 860-430-5687
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207QS1201X
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Taxonomy Name | Sleep Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 1223P0106X
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Taxonomy Name | Oral and Maxillofacial Pathology Dentistry
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License Number |
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License Number State |
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