Provider Demographics
NPI:1427189893
Name:GLASTONBURY DENTAL ASSOCIATES LLP
Entity Type:Organization
Organization Name:GLASTONBURY DENTAL ASSOCIATES LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SUSAT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-633-3671
Mailing Address - Street 1:416 NEW LONDON TPKE
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2237
Mailing Address - Country:US
Mailing Address - Phone:860-633-3671
Mailing Address - Fax:860-633-9128
Practice Address - Street 1:416 NEW LONDON TPKE
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2237
Practice Address - Country:US
Practice Address - Phone:860-633-3671
Practice Address - Fax:860-633-9128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTZ12996OtherBC MA PROVIDER ID-GROUP
CT20772-1OtherUHC-GROUP