Provider Demographics
NPI:1164803037
Name:CONNECTICUT DENTAL PARTNERS, LLC
Entity Type:Organization
Organization Name:CONNECTICUT DENTAL PARTNERS, LLC
Other - Org Name:CT DENTAL PARTNERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-314-9493
Mailing Address - Street 1:240 POMEROY AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-7170
Mailing Address - Country:US
Mailing Address - Phone:203-314-9493
Mailing Address - Fax:203-200-7953
Practice Address - Street 1:240 POMEROY AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-7170
Practice Address - Country:US
Practice Address - Phone:203-314-9493
Practice Address - Fax:203-200-7953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-16
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT011373122300000X
CT003881124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty