Provider Demographics
NPI:1750680435
Name:CGHE DENTAL LLC
Entity Type:Organization
Organization Name:CGHE DENTAL LLC
Other - Org Name:ATWILL CONROY DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTOFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGGARTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-351-3090
Mailing Address - Street 1:1196 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-2036
Mailing Address - Country:US
Mailing Address - Phone:401-351-3090
Mailing Address - Fax:401-331-1315
Practice Address - Street 1:1196 SMITH ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-2036
Practice Address - Country:US
Practice Address - Phone:401-351-3090
Practice Address - Fax:401-331-1315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI27441223G0001X
RI23501223G0001X
RI28371223G0001X
RI26631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty