Provider Demographics
NPI:1952481418
Name:DERMATOLOGY ASSOCIATES OF EASTERN CT LLC
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF EASTERN CT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENEDETTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-657-3376
Mailing Address - Street 1:622 HEBRON AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-5003
Mailing Address - Country:US
Mailing Address - Phone:860-657-3376
Mailing Address - Fax:860-633-6040
Practice Address - Street 1:622 HEBRON AVE STE 107
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-5003
Practice Address - Country:US
Practice Address - Phone:860-657-3376
Practice Address - Fax:860-633-6040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000275207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03281Medicare ID - Type Unspecified