Provider Demographics
NPI:1922179340
Name:STAFFORD DENTAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:STAFFORD DENTAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:M
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-684-5296
Mailing Address - Street 1:72 I WEST STAFFORD ROAD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD SPRINGS
Mailing Address - State:CT
Mailing Address - Zip Code:06076
Mailing Address - Country:US
Mailing Address - Phone:860-684-5296
Mailing Address - Fax:860-684-3370
Practice Address - Street 1:72 I WEST STAFFORD ROAD
Practice Address - Street 2:
Practice Address - City:STAFFORD SPRINGS
Practice Address - State:CT
Practice Address - Zip Code:06076
Practice Address - Country:US
Practice Address - Phone:860-684-5296
Practice Address - Fax:860-684-3370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty