Provider Demographics
NPI:1356642540
Name:MICHAEL A MANDINO JR D.D.S DR LOUIS A JULIANO D.D.S. LLC
Entity Type:Organization
Organization Name:MICHAEL A MANDINO JR D.D.S DR LOUIS A JULIANO D.D.S. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANDINO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-575-9798
Mailing Address - Street 1:276 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3022
Mailing Address - Country:US
Mailing Address - Phone:203-575-9798
Mailing Address - Fax:203-575-1286
Practice Address - Street 1:276 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3022
Practice Address - Country:US
Practice Address - Phone:203-575-9798
Practice Address - Fax:203-575-1286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4393122300000X
CT4750122300000X
CT10118122300000X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty