Provider Demographics
NPI:1942450754
Name:SPH ENTERPRISE LLC
Entity Type:Organization
Organization Name:SPH ENTERPRISE LLC
Other - Org Name:SHELTON DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEVRIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-342-4141
Mailing Address - Street 1:169 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484
Mailing Address - Country:US
Mailing Address - Phone:203-295-9425
Mailing Address - Fax:203-922-9322
Practice Address - Street 1:169 CENTER ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484
Practice Address - Country:US
Practice Address - Phone:203-925-9425
Practice Address - Fax:203-922-9322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-29
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0098461223G0001X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty