=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821565128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPRINGDALE DENTAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2018
-----------------------------------------------------
Last Update Date | 10/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1081 HOPE ST STE A
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06907-1824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 475-217-0668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1081 HOPE ST STE A
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06907-1824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 475-217-0668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | MRS. JOANNE ARNOLD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 475-217-0668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------