Provider Demographics
NPI:1407145204
Name:RENAISSANCE DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:RENAISSANCE DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUEY-JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:TSAI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-321-7715
Mailing Address - Street 1:11 SOUTH ROAD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032
Mailing Address - Country:US
Mailing Address - Phone:860-321-7715
Mailing Address - Fax:860-321-7617
Practice Address - Street 1:11 SOUTH ROAD
Practice Address - Street 2:SUITE 210
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032
Practice Address - Country:US
Practice Address - Phone:860-321-7715
Practice Address - Fax:860-321-7617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT80501223G0001X
CT91731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty