Provider Demographics
NPI:1225028657
Name:CHILDREN'S DENTAL ASSOCIATES OF NLC, PC
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL ASSOCIATES OF NLC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HERTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-886-5576
Mailing Address - Street 1:392 SALEM TPKE
Mailing Address - Street 2:
Mailing Address - City:BOZRAH
Mailing Address - State:CT
Mailing Address - Zip Code:06334-1519
Mailing Address - Country:US
Mailing Address - Phone:860-886-5576
Mailing Address - Fax:860-885-1379
Practice Address - Street 1:392 SALEM TPKE
Practice Address - Street 2:
Practice Address - City:BOZRAH
Practice Address - State:CT
Practice Address - Zip Code:06334-1519
Practice Address - Country:US
Practice Address - Phone:860-886-5576
Practice Address - Fax:860-885-1379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004119211Medicaid