MEDICARE: ASPEN DENTAL OF GREATER HARTFORD, PC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1215154067
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASPEN DENTAL OF GREATER HARTFORD, PC

Provider Business Mailing Address
First Line	:	PO BOX 3189
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13220-3189
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1128 FARMINGTON AVE
Second Line	:
City	:	BRISTOL
State	:	CT
Zip	:	06010-4752
Country	:	US
Telephone Number	:	860-585-1716
Fax Number	:

Authorized Official
Title or Position	:	MCD
Name	:	YUTDHASAK KJORNRATTANAWANICH
Credential	:
Telephone Number	:	315-454-6000

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	08/22/2020

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