Provider Demographics
NPI:1164842506
Name:LIFE LONG DENTAL CARE OF COLCHESTER LLC
Entity Type:Organization
Organization Name:LIFE LONG DENTAL CARE OF COLCHESTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-537-1444
Mailing Address - Street 1:151 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-1056
Mailing Address - Country:US
Mailing Address - Phone:860-537-1444
Mailing Address - Fax:
Practice Address - Street 1:151 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-1056
Practice Address - Country:US
Practice Address - Phone:860-537-1444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty