Provider Demographics
NPI:1265863518
Name:ADDISON VILLAGE DENTAL, INC
Entity Type:Organization
Organization Name:ADDISON VILLAGE DENTAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:VATAFU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-752-2005
Mailing Address - Street 1:969 HEBRON AVE
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-5033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:969 HEBRON AVE
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-5033
Practice Address - Country:US
Practice Address - Phone:646-752-2005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-11
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0095151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty