MEDICARE: STONINGTON DENTAL ASSOCIATES PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	12125	CT

General Provider Information

NPI Number	:	1043707755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STONINGTON DENTAL ASSOCIATES PLLC

Provider Business Mailing Address
First Line	:	20 S ANGUILLA RD
Second Line	:
City	:	PAWCATUCK
State	:	CT
Zip	:	06379-1447
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 S ANGUILLA RD
Second Line	:
City	:	PAWCATUCK
State	:	CT
Zip	:	06379-1447
Country	:	US
Telephone Number	:	860-599-2505
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MS. AMANDA KIRWIN
Credential	:
Telephone Number	:	401-578-0274

Provider Enumeration Date	:	04/18/2018
Last Update Date	:	10/30/2019

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