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General NPI Number Information
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NPI Number | 1619390853
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Entity Type | Organization
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Legal Business Name | STATE DENTAL
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Dates
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Enumeration Date | 01/23/2014
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Last Update Date | 01/23/2014
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Provider Practice Location Address
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Address Line | 1336 W MAIN ST SUITE 2B
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City | WATERBURY
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State | CT
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Zip | 06708-3122
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Country | US
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Telephone | 203-754-4175
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Fax | 203-596-1917
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Provider Business Mailing Address
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Address Line | 1336 W MAIN ST SUITE 2B
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City | WATERBURY
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State | CT
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Zip | 06708-3122
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Country | US
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Telephone | 203-754-4175
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Fax | 203-596-1917
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Authorized Official
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Title or Position | DENTIST
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Name | DR. MARK HOROWITZ
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Credential | DMD
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Telephone | 203-754-4175
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 006616
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License Number State | CT
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