Provider Demographics
NPI:1447596408
Name:GLASTONBURY FAMILY DENTAL PC
Entity Type:Organization
Organization Name:GLASTONBURY FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:COHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-633-6246
Mailing Address - Street 1:2450 MAIN ST
Mailing Address - Street 2:STE 1
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2041
Mailing Address - Country:US
Mailing Address - Phone:860-633-6246
Mailing Address - Fax:860-633-1808
Practice Address - Street 1:2450 MAIN ST
Practice Address - Street 2:STE 1
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2041
Practice Address - Country:US
Practice Address - Phone:860-633-6246
Practice Address - Fax:860-633-1808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0082881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty