Provider Demographics
NPI:1669669982
Name:DARTMOUTH ENDOCRINOLOGY LLC
Entity Type:Organization
Organization Name:DARTMOUTH ENDOCRINOLOGY LLC
Other - Org Name:DARTMOUTH ENDOCRINOLOGY, DIABETES AND METABOLISM, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOMBASSEI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-679-0234
Mailing Address - Street 1:44 DALE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-4351
Mailing Address - Country:US
Mailing Address - Phone:860-679-0234
Mailing Address - Fax:860-606-0060
Practice Address - Street 1:44 DALE RD STE 201
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-4351
Practice Address - Country:US
Practice Address - Phone:860-679-0234
Practice Address - Fax:860-606-0060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032434207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTDD9711Medicare PIN
CTC03361Medicare PIN