Provider Demographics
NPI:1558591586
Name:GALES FERRY ORTHODONTICS LLC
Entity Type:Organization
Organization Name:GALES FERRY ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:D
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,PC
Authorized Official - Phone:860-464-7204
Mailing Address - Street 1:1527 ROUTE 12
Mailing Address - Street 2:P.O. BOX 395
Mailing Address - City:GALES FERRY
Mailing Address - State:CT
Mailing Address - Zip Code:06335-1800
Mailing Address - Country:US
Mailing Address - Phone:860-464-7204
Mailing Address - Fax:860-464-0186
Practice Address - Street 1:1527 ROUTE 12
Practice Address - Street 2:
Practice Address - City:GALES FERRY
Practice Address - State:CT
Practice Address - Zip Code:06335-1800
Practice Address - Country:US
Practice Address - Phone:860-464-7204
Practice Address - Fax:860-464-0186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-24
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0048141223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty