Provider Demographics
NPI:1295374296
Name:THE SMILE STUDIO AT BUSHNELL PARK
Entity Type:Organization
Organization Name:THE SMILE STUDIO AT BUSHNELL PARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-728-5264
Mailing Address - Street 1:1 GOLD ST STE Q
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06103-2914
Mailing Address - Country:US
Mailing Address - Phone:860-728-5264
Mailing Address - Fax:
Practice Address - Street 1:1 GOLD ST STE Q
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06103-2914
Practice Address - Country:US
Practice Address - Phone:860-728-5264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1093881534OtherNPI