MEDICARE: CHILDREN'S DENTAL ASSOCIATES OF NLC, 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	1223P0221X	Pediatric Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225028657
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN'S DENTAL ASSOCIATES OF NLC, PC

Provider Business Mailing Address
First Line	:	392 SALEM TPKE
Second Line	:
City	:	BOZRAH
State	:	CT
Zip	:	06334-1519
Country	:	US
Telephone Number	:	860-886-5576
Fax Number	:	860-885-1379

Provider Business Practice Location Address
First Line	:	392 SALEM TPKE
Second Line	:
City	:	BOZRAH
State	:	CT
Zip	:	06334-1519
Country	:	US
Telephone Number	:	860-886-5576
Fax Number	:	860-885-1379

Authorized Official
Title or Position	:	MANGER
Name	:	MRS. MICHELLE S HERTER
Credential	:
Telephone Number	:	860-886-5576

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	01/11/2011

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