Provider Demographics
NPI:1558687103
Name:SPH2 ENTERPRISE LLC
Entity Type:Organization
Organization Name:SPH2 ENTERPRISE LLC
Other - Org Name:MERIDEN FAMILY DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVRIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-342-4141
Mailing Address - Street 1:553 PORTLAND COBALT RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06480-1968
Mailing Address - Country:US
Mailing Address - Phone:860-342-4141
Mailing Address - Fax:860-342-1284
Practice Address - Street 1:470 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-2103
Practice Address - Country:US
Practice Address - Phone:860-342-4141
Practice Address - Fax:860-342-1284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-07
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0097851223G0001X
CT0098461223G0001X
CT0099201223G0001X
1223P0106X, 1223P0221X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty