Provider Demographics
NPI:1629760244
Name:NEDG-AVON PLLC
Entity Type:Organization
Organization Name:NEDG-AVON PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LACLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-281-6464
Mailing Address - Street 1:257 TURNPIKE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1791
Mailing Address - Country:US
Mailing Address - Phone:508-281-6464
Mailing Address - Fax:
Practice Address - Street 1:1216 FARMINGTON AVE STE 201
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2673
Practice Address - Country:US
Practice Address - Phone:860-561-4378
Practice Address - Fax:860-561-4384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental