Provider Demographics
NPI:1013629369
Name:ST. BERNARD DENTISTRY PLLC
Entity Type:Organization
Organization Name:ST. BERNARD DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER /OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ST. BERNARD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-751-2470
Mailing Address - Street 1:28 BRIGHTON DR
Mailing Address - Street 2:
Mailing Address - City:EAST GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06026-9423
Mailing Address - Country:US
Mailing Address - Phone:860-751-2470
Mailing Address - Fax:
Practice Address - Street 1:697 POQUONOCK AVE UNIT 7
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-2249
Practice Address - Country:US
Practice Address - Phone:860-219-0933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental