Provider Demographics
NPI:1881859809
Name:WINDSOR LOCKS DENTAL CARE LLC
Entity Type:Organization
Organization Name:WINDSOR LOCKS DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FOTIOS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUMOULIDIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-627-9784
Mailing Address - Street 1:73 OLD COUNTY RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR LOCKS
Mailing Address - State:CT
Mailing Address - Zip Code:06096-1564
Mailing Address - Country:US
Mailing Address - Phone:860-627-9784
Mailing Address - Fax:860-654-1679
Practice Address - Street 1:73 OLD COUNTY RD
Practice Address - Street 2:
Practice Address - City:WINDSOR LOCKS
Practice Address - State:CT
Practice Address - Zip Code:06096-1564
Practice Address - Country:US
Practice Address - Phone:860-627-9784
Practice Address - Fax:860-654-1679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-21
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty