=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467555995
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FARMINGTON VALLEY ORTHODONTIC ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 WEST AVON ROAD SUITE 102
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-673-6105
-----------------------------------------------------
Fax | 860-673-6111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 WEST AVON ROAD SUITE 102
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-673-6105
-----------------------------------------------------
Fax | 860-673-6111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PARTNER ORTHODONTIST
-----------------------------------------------------
Name | PHILIP J DEPASQUALE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 860-673-6105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 4410
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 6213
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------