Provider Demographics
NPI:1265942676
Name:ADVANCED DENTAL OF CROMWELL LLC
Entity type:Organization
Organization Name:ADVANCED DENTAL OF CROMWELL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAROON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-894-2933
Mailing Address - Street 1:26 SHUNPIKE RD STE A
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-2442
Mailing Address - Country:US
Mailing Address - Phone:860-894-2933
Mailing Address - Fax:860-828-1610
Practice Address - Street 1:26 SHUNPIKE RD STE A
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-2442
Practice Address - Country:US
Practice Address - Phone:860-894-2933
Practice Address - Fax:860-828-1610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CTCT0069681223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty