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General NPI Number Information
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NPI Number | 1376663609
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Entity Type | Organization
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Legal Business Name | AVON VILLAGE FAMILY DENTISTRY
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Dates
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Enumeration Date | 03/30/2007
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Last Update Date | 02/05/2024
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Provider Practice Location Address
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Address Line | 32 EAST MAIN STREET
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City | AVON
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State | CT
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Zip | 06001-1039
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Country | US
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Telephone | 860-678-1140
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Fax | 860-284-4423
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Provider Business Mailing Address
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Address Line | 32 EAST MAIN STREET
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City | AVON
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State | CT
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Zip | 06001-1039
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Country | US
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Telephone | 860-678-1140
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Fax | 860-284-4423
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Authorized Official
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Title or Position | OWNER
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Name | MS. LAUREN M MENTASTI
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Credential | DMD
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Telephone | 860-678-1140
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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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 | 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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