MEDICARE: BRISTOL PLAZA FAMILY DENTAL

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	122300000X	Dentist

General Provider Information

NPI Number	:	1285953653
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRISTOL PLAZA FAMILY DENTAL

Provider Business Mailing Address
First Line	:	1192 FARMINGTON AVE
Second Line	:	UNIT D
City	:	BRISTOL
State	:	CT
Zip	:	06010-4752
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1192 FARMINGTON AVE
Second Line	:	UNIT D
City	:	BRISTOL
State	:	CT
Zip	:	06010-4752
Country	:	US
Telephone Number	:	860-223-2000
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JULIA FAIGEL
Credential	:
Telephone Number	:	860-223-2000

Provider Enumeration Date	:	05/25/2010
Last Update Date	:	05/25/2010

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