Provider Demographics
NPI:1730637703
Name:CLINTON FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:CLINTON FAMILY DENTISTRY, LLC
Other - Org Name:CLINTON FAMILY DENTISTRY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:PANAGROSSI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-669-2700
Mailing Address - Street 1:145R E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:CT
Mailing Address - Zip Code:06413-2104
Mailing Address - Country:US
Mailing Address - Phone:860-669-2700
Mailing Address - Fax:
Practice Address - Street 1:145R E MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:CT
Practice Address - Zip Code:06413-2104
Practice Address - Country:US
Practice Address - Phone:860-669-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLINTON FAMILY DENTISTRY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7503122300000X
CT8902122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty