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General NPI Number Information
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NPI Number | 1518234079
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Entity Type | Organization
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Legal Business Name | PARK STREET FAMILY DENTAL
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Dates
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Enumeration Date | 11/28/2011
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Last Update Date | 11/28/2011
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Provider Practice Location Address
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Address Line | 454 PARK ST
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City | HARTFORD
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State | CT
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Zip | 06106-1525
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Country | US
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Telephone | 860-944-2802
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Fax |
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Provider Business Mailing Address
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Address Line | 454 PARK ST
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City | HARTFORD
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State | CT
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Zip | 06106-1525
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Country | US
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Telephone | 860-944-2802
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KRISHNAPRASANTH MUDUSU
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Credential | DMD
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Telephone | 860-944-2802
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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 | 010554
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License Number State | CT
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