Provider Demographics
NPI:1376663609
Name:AVON VILLAGE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:AVON VILLAGE FAMILY DENTISTRY
Other - Org Name:AVON VILLAGE FAMILY DENTISTRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MENTASTI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-678-1140
Mailing Address - Street 1:32 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-1039
Mailing Address - Country:US
Mailing Address - Phone:860-678-1140
Mailing Address - Fax:860-284-4423
Practice Address - Street 1:32 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-1039
Practice Address - Country:US
Practice Address - Phone:860-678-1140
Practice Address - Fax:860-284-4423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT7587810001Medicaid