Provider Demographics
NPI:1164745956
Name:DENTAL GROUP OF WATERBURY, LLC
Entity Type:Organization
Organization Name:DENTAL GROUP OF WATERBURY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAMAYO-BORDIES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203203-573-9989
Mailing Address - Street 1:1127 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2764
Mailing Address - Country:US
Mailing Address - Phone:203-573-9989
Mailing Address - Fax:203-759-0239
Practice Address - Street 1:1127 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2764
Practice Address - Country:US
Practice Address - Phone:203-573-9989
Practice Address - Fax:203-759-0239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-08
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008810122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty