Provider Demographics
NPI:1770024085
Name:HWANG LONG TERM DENTAL
Entity Type:Organization
Organization Name:HWANG LONG TERM DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HWANG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:475-238-8165
Mailing Address - Street 1:PO BOX 7227
Mailing Address - Street 2:174 SCOTT ROAD
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06787-1300
Mailing Address - Country:US
Mailing Address - Phone:475-238-8165
Mailing Address - Fax:475-655-2967
Practice Address - Street 1:174 SCOTT RD
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1300
Practice Address - Country:US
Practice Address - Phone:475-238-8165
Practice Address - Fax:475-655-2967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009577122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1568685352Medicaid