Provider Demographics
NPI:1730464470
Name:EVERGREEN DENTAL LLC
Entity Type:Organization
Organization Name:EVERGREEN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIKAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GOEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-298-0446
Mailing Address - Street 1:5213 AVALON DR W
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-3677
Mailing Address - Country:US
Mailing Address - Phone:203-298-0466
Mailing Address - Fax:
Practice Address - Street 1:109 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3235
Practice Address - Country:US
Practice Address - Phone:203-298-0446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-13
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT010332122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty