Provider Demographics
NPI:1275734824
Name:ORTHODONTIC ASSOCIATES OF SOUTHEASTERN CONNECTICUT, P.C.
Entity Type:Organization
Organization Name:ORTHODONTIC ASSOCIATES OF SOUTHEASTERN CONNECTICUT, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:ADRIAN
Authorized Official - Last Name:HACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-443-1827
Mailing Address - Street 1:196 PARKWAY S
Mailing Address - Street 2:SUITE 305
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1234
Mailing Address - Country:US
Mailing Address - Phone:860-443-1827
Mailing Address - Fax:860-443-1745
Practice Address - Street 1:196 PARKWAY S
Practice Address - Street 2:SUITE 305
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1234
Practice Address - Country:US
Practice Address - Phone:860-443-1827
Practice Address - Fax:860-443-1745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0077231223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty