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General NPI Number Information
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NPI Number | 1578730578
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Entity Type | Organization
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Legal Business Name | HAWLEY LANE DENTAL LLC
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Dates
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Enumeration Date | 05/09/2008
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Last Update Date | 05/09/2008
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Provider Practice Location Address
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Address Line | 475 HAWLEY LANE UNIT 9
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City | STRATFORD
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State | CT
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Zip | 06614
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Country | US
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Telephone | 203-377-9300
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Fax | 203-377-9301
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Provider Business Mailing Address
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Address Line | 475 HAWLEY LANE UNIT 9
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City | STRATFORD
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State | CT
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Zip | 06614
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Country | US
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Telephone | 203-377-9300
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Fax | 203-377-9301
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Authorized Official
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Title or Position | MEMBER
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Name | DR. KRISTY L GRETZULA
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Credential | DDS
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Telephone | 203-377-9300
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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 | 9459
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License Number State | CT
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