Provider Demographics
NPI:1790004885
Name:MY ENFIELD DENTIST, LLC
Entity Type:Organization
Organization Name:MY ENFIELD DENTIST, LLC
Other - Org Name:ESSEL DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAKESH
Authorized Official - Middle Name:
Authorized Official - Last Name:KUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-254-6955
Mailing Address - Street 1:44 S MAIN ST STE 14
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06088-1702
Mailing Address - Country:US
Mailing Address - Phone:860-254-6955
Mailing Address - Fax:860-254-6956
Practice Address - Street 1:44 S MAIN ST STE 14
Practice Address - Street 2:
Practice Address - City:EAST WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06088-1702
Practice Address - Country:US
Practice Address - Phone:860-254-6955
Practice Address - Fax:860-254-6956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-27
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0101891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008017210Medicaid