Provider Demographics
NPI:1578730578
Name:HAWLEY LANE DENTAL LLC
Entity Type:Organization
Organization Name:HAWLEY LANE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRETZULA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-377-9300
Mailing Address - Street 1:475 HAWLEY LANE
Mailing Address - Street 2:UNIT 9
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614
Mailing Address - Country:US
Mailing Address - Phone:203-377-9300
Mailing Address - Fax:203-377-9301
Practice Address - Street 1:475 HAWLEY LANE
Practice Address - Street 2:UNIT 9
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614
Practice Address - Country:US
Practice Address - Phone:203-377-9300
Practice Address - Fax:203-377-9301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT94591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty