Provider Demographics
NPI:1760716401
Name:DR. ALTMAN AND DR. KWON DENTAL GROUP
Entity Type:Organization
Organization Name:DR. ALTMAN AND DR. KWON DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-528-3350
Mailing Address - Street 1:1011 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108
Mailing Address - Country:US
Mailing Address - Phone:860-528-3350
Mailing Address - Fax:860-289-6875
Practice Address - Street 1:1011 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-2294
Practice Address - Country:US
Practice Address - Phone:860-528-3350
Practice Address - Fax:860-289-6875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4715122300000X
CT10110122300000X
CT100041223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1053481267Medicaid
CT1770759961Medicaid
CT1093048290Medicaid