Provider Demographics
NPI:1629364997
Name:NEW LONDON DENTAL CARE, LLC
Entity Type:Organization
Organization Name:NEW LONDON DENTAL CARE, LLC
Other - Org Name:NEW LONDON DENTAL CARE
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 1:258 S FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-2641
Practice Address - Country:US
Practice Address - Phone:860-437-3462
Practice Address - Fax:860-437-3485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-24
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT99201223G0001X
1223P0221X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty