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General NPI Number Information
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NPI Number | 1699185264
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Entity Type | Organization
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Legal Business Name | CREST FAMILY DENTAL, LLC
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Dates
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Enumeration Date | 05/05/2014
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Last Update Date | 05/05/2014
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Provider Practice Location Address
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Address Line | 85 SEYMOUR ST SUITE 1018
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City | HARTFORD
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State | CT
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Zip | 06106-5501
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Country | US
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Telephone | 860-251-6999
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Fax | 860-251-6997
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Provider Business Mailing Address
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Address Line | 85 SEYMOUR ST SUITE 1018
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City | HARTFORD
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State | CT
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Zip | 06106-5501
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Country | US
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Telephone | 860-251-6999
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Fax | 860-251-6997
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Authorized Official
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Title or Position | MANAGER
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Name | DR. SHYAM SHIVAREDDY
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Credential |
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Telephone | 904-514-1217
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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 | CT10690
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License Number State | CT
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