Provider Demographics
NPI:1386035707
Name:MODERN FAMILY DENTAL
Entity Type:Organization
Organization Name:MODERN FAMILY DENTAL
Other - Org Name:SGROUP LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MROWKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-437-3462
Mailing Address - Street 1:320 BOSTON AVE
Mailing Address - Street 2:SUITE 17
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-5213
Mailing Address - Country:US
Mailing Address - Phone:860-437-3462
Mailing Address - Fax:860-437-3485
Practice Address - Street 1:360 BOSTON AVE
Practice Address - Street 2:SUITE 17
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-5213
Practice Address - Country:US
Practice Address - Phone:860-437-3462
Practice Address - Fax:860-437-3485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-06
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
CT1223P0221X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1386035707Medicaid
CT1942579768Medicaid