Provider Demographics
NPI:1417452541
Name:BLOOMFIELD PEDIATRIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:BLOOMFIELD PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-927-0717
Mailing Address - Street 1:138 BALFOUR DR
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-2900
Mailing Address - Country:US
Mailing Address - Phone:860-521-2316
Mailing Address - Fax:
Practice Address - Street 1:34 JEROME AVE STE 200
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2463
Practice Address - Country:US
Practice Address - Phone:203-927-0717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT78291223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty