Provider Demographics
NPI:1790920213
Name:RONALD D. KIRSCHBAUM DMD
Entity Type:Organization
Organization Name:RONALD D. KIRSCHBAUM DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:KIRSCHBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-668-6128
Mailing Address - Street 1:230A MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078-2082
Mailing Address - Country:US
Mailing Address - Phone:860-668-6128
Mailing Address - Fax:860-386-6736
Practice Address - Street 1:230A MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SUFFIELD
Practice Address - State:CT
Practice Address - Zip Code:06078-2082
Practice Address - Country:US
Practice Address - Phone:860-668-6128
Practice Address - Fax:860-386-6736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT72831223G0001X
CT72821223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty