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General NPI Number Information
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NPI Number | 1629263850
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Entity Type | Organization
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Legal Business Name | BRASS MILL MALL DENTAL L.L.P
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Dates
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Enumeration Date | 09/11/2007
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Last Update Date | 03/18/2015
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Provider Practice Location Address
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Address Line | 495 UNION ST STUITE 1016
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City | WATERBURY
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State | CT
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Zip | 06706-1292
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Country | US
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Telephone | 203-574-2121
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Fax |
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Provider Business Mailing Address
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Address Line | 495 UNION ST STUITE 1016
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City | WATERBURY
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State | CT
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Zip | 06706-1292
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Country | US
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Telephone | 203-574-2121
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. ROSS KRASNOV
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Credential |
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Telephone | 860-676-2828
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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 | 008698
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License Number State | CT
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