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General NPI Number Information
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NPI Number | 1588005243
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Entity Type | Organization
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Legal Business Name | TOOTH & GUMS DENTISTRY
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Dates
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Enumeration Date | 07/10/2013
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Last Update Date | 11/07/2013
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Provider Practice Location Address
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Address Line | 1500 ALBANY AVE
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City | HARTFORD
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State | CT
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Zip | 06112-2113
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Country | US
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Telephone | 860-293-2003
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Fax | 860-293-2007
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Provider Business Mailing Address
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Address Line | 1500 ALBANY AVE
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City | HARTFORD
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State | CT
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Zip | 06112-2113
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Country | US
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Telephone | 860-293-2003
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Fax | 860-293-2007
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Authorized Official
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Title or Position | OWNER
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Name | AVIRAL CHANDRA
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Credential | DMD
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Telephone | 860-293-2003
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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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