Provider Demographics
NPI:1245569748
Name:SPH2 ENTERPRISE, LLC
Entity type:Organization
Organization Name:SPH2 ENTERPRISE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVRIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-342-4141
Mailing Address - Street 1:191 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06114
Mailing Address - Country:US
Mailing Address - Phone:860-296-7460
Mailing Address - Fax:860-296-7459
Practice Address - Street 1:191 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114
Practice Address - Country:US
Practice Address - Phone:860-296-7460
Practice Address - Fax:860-296-7459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-11
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT0098461223G0001X
CTCT0097851223G0001X
CTCT0099201223G0001X
CT1223P0106X, 1223P0221X
1223S0112X
CT98461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008002144Medicaid
CT008002145Medicaid
CT008002146Medicaid