Provider Demographics
NPI:1164719456
Name:ORAL CARE DENTAL GROUP II, LLC
Entity Type:Organization
Organization Name:ORAL CARE DENTAL GROUP II, LLC
Other - Org Name:SMILES OF HARTFORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS/FINANCE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTA MARIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-444-9345
Mailing Address - Street 1:330 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-1860
Mailing Address - Country:US
Mailing Address - Phone:860-444-9345
Mailing Address - Fax:860-443-0432
Practice Address - Street 1:330 MAIN ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1860
Practice Address - Country:US
Practice Address - Phone:860-444-9345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT87271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT8727OtherCONNECTICUT STATE DENTAL LICENSE
CT002087270Medicaid