Provider Demographics
NPI:1326428889
Name:CONNECTICUT CENTER FOR RESTORATIVE DENTISTRY
Entity Type:Organization
Organization Name:CONNECTICUT CENTER FOR RESTORATIVE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUENG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-591-7895
Mailing Address - Street 1:202 WATER ST
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-2843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:202 WATER ST
Practice Address - Street 2:
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-2843
Practice Address - Country:US
Practice Address - Phone:203-723-1901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-31
Last Update Date:2015-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT010593122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty