=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619754736
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURPLE DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2023
-----------------------------------------------------
Last Update Date | 09/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2963 MAIN ST
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-1028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-327-6453
-----------------------------------------------------
Fax | 860-251-6997
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2963 MAIN ST
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-1028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-327-6453
-----------------------------------------------------
Fax | 860-251-6997
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. POORNIMA KADAGAD
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 857-241-7964
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------