Provider Demographics
NPI:1568674331
Name:ADVANTAGE DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:ADVANTAGE DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:VAN LEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-691-0025
Mailing Address - Street 1:339 FLANDERS RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:EAST LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06333
Mailing Address - Country:US
Mailing Address - Phone:860-691-0025
Mailing Address - Fax:
Practice Address - Street 1:339 FLANDERS RD
Practice Address - Street 2:SUITE 105
Practice Address - City:EAST LYME
Practice Address - State:CT
Practice Address - Zip Code:06333
Practice Address - Country:US
Practice Address - Phone:860-691-0025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT79281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty