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General NPI Number Information
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NPI Number | 1295374296
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Entity Type | Organization
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Legal Business Name | THE SMILE STUDIO AT BUSHNELL PARK
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Dates
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Enumeration Date | 12/23/2019
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Last Update Date | 12/23/2019
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Provider Practice Location Address
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Address Line | 1 GOLD ST STE Q
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City | HARTFORD
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State | CT
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Zip | 06103-2914
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Country | US
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Telephone | 860-728-5264
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Fax |
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Provider Business Mailing Address
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Address Line | 1 GOLD ST STE Q
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City | HARTFORD
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State | CT
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Zip | 06103-2914
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Country | US
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Telephone | 860-728-5264
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BRYAN WILSON
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Credential | DDS
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Telephone | 860-728-5264
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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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