Provider Demographics
NPI:1699811075
Name:LAFAYETTE DENTAL GROUP, PC
Entity Type:Organization
Organization Name:LAFAYETTE DENTAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-889-5213
Mailing Address - Street 1:200 WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06073-2717
Mailing Address - Country:US
Mailing Address - Phone:860-659-3450
Mailing Address - Fax:
Practice Address - Street 1:67 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-3407
Practice Address - Country:US
Practice Address - Phone:860-889-5213
Practice Address - Fax:860-886-0100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT75681223G0001X
CT93451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1548343858OtherNPI NUMBER ISSUED
1651844OtherUNITED CONCORDIA
CT020007568CT03OtherANTHEM BCBS CT
1904629OtherUNITED CONCORDIA
CT020009345CT02OtherANTHEM BCBS CT
815896OtherUNITED CONCORDIA