Provider Demographics
NPI:1730644212
Name:RESOLUTE CROSS ROAD LLC
Entity Type:Organization
Organization Name:RESOLUTE CROSS ROAD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TOBACK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:860-443-2428
Mailing Address - Street 1:112 CROSS RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1204
Mailing Address - Country:US
Mailing Address - Phone:860-447-1787
Mailing Address - Fax:
Practice Address - Street 1:112 CROSS RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1204
Practice Address - Country:US
Practice Address - Phone:860-447-1787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental