Provider Demographics
NPI:1619390853
Name:STATE DENTAL
Entity Type:Organization
Organization Name:STATE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HOROWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-754-4175
Mailing Address - Street 1:1336 W MAIN ST
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3122
Mailing Address - Country:US
Mailing Address - Phone:203-754-4175
Mailing Address - Fax:203-596-1917
Practice Address - Street 1:1336 W MAIN ST
Practice Address - Street 2:SUITE 2B
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3122
Practice Address - Country:US
Practice Address - Phone:203-754-4175
Practice Address - Fax:203-596-1917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006616122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004116704Medicaid
CT002066167Medicaid