Provider Demographics
NPI:1821369968
Name:ALBANY AVENUE DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:ALBANY AVENUE DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:A
Authorized Official - Last Name:HENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-493-0653
Mailing Address - Street 1:1000 ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-2312
Mailing Address - Country:US
Mailing Address - Phone:860-493-0653
Mailing Address - Fax:860-493-0654
Practice Address - Street 1:1000 ALBANY AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-2312
Practice Address - Country:US
Practice Address - Phone:860-493-0653
Practice Address - Fax:860-493-0654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT010641122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty