Provider Demographics
NPI:1679822571
Name:FAMILY DENTISTRY OF HARTFORD, LLC
Entity Type:Organization
Organization Name:FAMILY DENTISTRY OF HARTFORD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-733-0574
Mailing Address - Street 1:18 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-2324
Mailing Address - Country:US
Mailing Address - Phone:860-206-4960
Mailing Address - Fax:
Practice Address - Street 1:18 MADISON ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-2324
Practice Address - Country:US
Practice Address - Phone:860-206-4960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT55691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty