MEDICARE: GLASTONBURY DENTAL GROUP LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0	OTHER	CT	GENERAL DENTIST

General Provider Information

NPI Number	:	1215641147
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLASTONBURY DENTAL GROUP LLC

Provider Business Mailing Address
First Line	:	29 UPDIKE AVE
Second Line	:
City	:	NORTH KINGSTOWN
State	:	RI
Zip	:	02852-5728
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	141 HEBRON AVE STE 3
Second Line	:
City	:	GLASTONBURY
State	:	CT
Zip	:	06033-4200
Country	:	US
Telephone Number	:	860-633-5467
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	MICHAEL CAPALBO
Credential	:	DO
Telephone Number	:	401-741-7395

Provider Enumeration Date	:	01/05/2023
Last Update Date	:	04/22/2026

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