Provider Demographics
NPI:1922633213
Name:THE DERMATOLOGY CENTER OF CONNECTICUT, LLC
Entity Type:Organization
Organization Name:THE DERMATOLOGY CENTER OF CONNECTICUT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:BOLDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-907-8474
Mailing Address - Street 1:1790 CHESHIRE ST
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-1237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 CHURCH ST UNIT 4B
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2340
Practice Address - Country:US
Practice Address - Phone:203-907-8474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty