Provider Demographics
NPI:1912394834
Name:CONNECTICUT SMILES LLC
Entity Type:Organization
Organization Name:CONNECTICUT SMILES LLC
Other - Org Name:KRISTAL SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-754-7100
Mailing Address - Street 1:427 STILLSON RD STE 12
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-3158
Mailing Address - Country:US
Mailing Address - Phone:203-374-0512
Mailing Address - Fax:203-372-0280
Practice Address - Street 1:109 WATERTOWN AVE STE 1
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2623
Practice Address - Country:US
Practice Address - Phone:203-754-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0058251223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP002058253Medicaid