Provider Demographics
NPI:1164564761
Name:SUFFIELD VILLAGE DENTAL
Entity Type:Organization
Organization Name:SUFFIELD VILLAGE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-668-4431
Mailing Address - Street 1:215 SUFFIELD VLG
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078-2122
Mailing Address - Country:US
Mailing Address - Phone:860-668-4431
Mailing Address - Fax:
Practice Address - Street 1:215 SUFFIELD VLG
Practice Address - Street 2:
Practice Address - City:SUFFIELD
Practice Address - State:CT
Practice Address - Zip Code:06078-2122
Practice Address - Country:US
Practice Address - Phone:860-668-4431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT41371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty