Provider Demographics
NPI:1235369794
Name:DENTAL GROUP OF MERIDEN-WALLINGFORD
Entity Type:Organization
Organization Name:DENTAL GROUP OF MERIDEN-WALLINGFORD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNITA
Authorized Official - Middle Name:
Authorized Official - Last Name:KALLURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-235-5588
Mailing Address - Street 1:298 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-5853
Mailing Address - Country:US
Mailing Address - Phone:203-235-5588
Mailing Address - Fax:203-630-3021
Practice Address - Street 1:298 BROAD ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-5853
Practice Address - Country:US
Practice Address - Phone:203-235-5588
Practice Address - Fax:203-630-3021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-19
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT41081223G0001X
CT78061223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty