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General NPI Number Information
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NPI Number | 1750680435
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Entity Type | Organization
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Legal Business Name | CGHE DENTAL LLC
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Dates
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Enumeration Date | 03/21/2011
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Last Update Date | 03/21/2011
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Provider Practice Location Address
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Address Line | 1196 SMITH ST
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City | PROVIDENCE
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State | RI
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Zip | 02908-2036
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Country | US
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Telephone | 401-351-3090
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Fax | 401-331-1315
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Provider Business Mailing Address
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Address Line | 1196 SMITH ST
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City | PROVIDENCE
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State | RI
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Zip | 02908-2036
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Country | US
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Telephone | 401-351-3090
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Fax | 401-331-1315
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Authorized Official
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Title or Position | MEMBER
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Name | DR. KRISTOFER HAGGARTY
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Credential | DMD
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Telephone | 401-351-3090
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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 | 2350
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License Number State | RI
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2837
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License Number State | RI
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2663
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License Number State | RI
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Taxonomy #4
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2744
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License Number State | RI
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