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General NPI Number Information
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NPI Number | 1508136425
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Entity Type | Organization
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Legal Business Name | TODDLESR TO TEENS PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 01/09/2012
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Last Update Date | 01/17/2012
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Provider Practice Location Address
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Address Line | 1340 BOULEVARD
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City | WEST HARTFORD
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State | CT
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Zip | 06119-1901
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Country | US
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Telephone | 860-521-2500
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Fax | 860-521-2501
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Provider Business Mailing Address
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Address Line | 1340 BOULEVARD
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City | WEST HARTFORD
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State | CT
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Zip | 06119-1901
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Country | US
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Telephone | 860-521-2500
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Fax | 860-521-2501
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Authorized Official
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Title or Position | OWNER/ DIRECTOR
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Name | OSCAR GONZALEZ
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Credential | D.D.S.
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Telephone | 860-521-2500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 7093
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License Number State | CT
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