Provider Demographics
NPI:1972893352
Name:SPH3 ENTERPRISE, LLC
Entity Type:Organization
Organization Name:SPH3 ENTERPRISE, LLC
Other - Org Name:BUCKLAND HILLS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TAE
Authorized Official - Middle Name:CHUL
Authorized Official - Last Name:HO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-342-4141
Mailing Address - Street 1:553 PORTLAND-COBALT RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06480
Mailing Address - Country:US
Mailing Address - Phone:860-342-4141
Mailing Address - Fax:860-342-1284
Practice Address - Street 1:194 BUCKLAND HILLS DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-8705
Practice Address - Country:US
Practice Address - Phone:860-342-4141
Practice Address - Fax:860-342-1284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0098461223G0001X
CT0099201223G0001X
CT0097851223G0001X
1223P0106X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty