Provider Demographics
NPI:1770814956
Name:CONNECTICUT FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:CONNECTICUT FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:L
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-646-1704
Mailing Address - Street 1:945 MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-6064
Mailing Address - Country:US
Mailing Address - Phone:860-646-1704
Mailing Address - Fax:
Practice Address - Street 1:945 MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-6064
Practice Address - Country:US
Practice Address - Phone:860-646-1704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT45901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty