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General NPI Number Information
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NPI Number | 1619375813
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Entity Type | Organization
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Legal Business Name | ESTHETIC DENTAL GROUP LLC
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Dates
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Enumeration Date | 12/21/2014
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Last Update Date | 12/21/2014
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Provider Practice Location Address
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Address Line | 24 LISE CIR
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City | SUFFIELD
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State | CT
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Zip | 06078-1381
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Country | US
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Telephone | 860-956-5311
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Fax |
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Provider Business Mailing Address
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Address Line | 550 FARMINGTON AVE
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City | HARTFORD
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State | CT
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Zip | 06105-3040
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Country | US
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Telephone | 860-956-5311
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Fax |
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Authorized Official
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Title or Position | MEMBER OF LLC
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Name | DR. SACHIN VIRMANI
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Credential | DDS
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Telephone | 860-956-5311
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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 | 010564
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License Number State | CT
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