Provider Demographics
NPI:1982837845
Name:WINTONBURY DENTAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:WINTONBURY DENTAL ASSOCIATES, P.C.
Other - Org Name:WINTONBURY DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALPHONSO
Authorized Official - Middle Name:L
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-243-5451
Mailing Address - Street 1:2 WINTONBURY MALL
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-2466
Mailing Address - Country:US
Mailing Address - Phone:860-243-5451
Mailing Address - Fax:
Practice Address - Street 1:2 WINTONBURY MALL
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2466
Practice Address - Country:US
Practice Address - Phone:860-243-5451
Practice Address - Fax:860-656-6107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-26
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0058451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty