Provider Demographics
NPI:1639555451
Name:REIDVILLE DENTISTRY & IMPLANTS
Entity Type:Organization
Organization Name:REIDVILLE DENTISTRY & IMPLANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTA MARIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-997-0569
Mailing Address - Street 1:48 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-3414
Mailing Address - Country:US
Mailing Address - Phone:860-444-9345
Mailing Address - Fax:860-437-1938
Practice Address - Street 1:464 REIDVILLE DR
Practice Address - Street 2:SUITE A2
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-2650
Practice Address - Country:US
Practice Address - Phone:860-444-9345
Practice Address - Fax:860-437-1938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty