Provider Demographics
NPI:1417389636
Name:HOSPITAL DENTAL GROUP DDS PC
Entity Type:Organization
Organization Name:HOSPITAL DENTAL GROUP DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANATOLIY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-524-5194
Mailing Address - Street 1:85 SEYMOUR ST
Mailing Address - Street 2:SUITE 922
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-5501
Mailing Address - Country:US
Mailing Address - Phone:860-524-5194
Mailing Address - Fax:860-349-4571
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 922
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-524-5194
Practice Address - Fax:860-349-4571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008890320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities