Provider Demographics
NPI:1295889517
Name:GRANBY DENTAL, LLC
Entity type:Organization
Organization Name:GRANBY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:KIRSCHBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-653-7596
Mailing Address - Street 1:26 EAST GRANBY RD.
Mailing Address - Street 2:P.O. BOX 450
Mailing Address - City:GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06035-0450
Mailing Address - Country:US
Mailing Address - Phone:860-653-7596
Mailing Address - Fax:860-653-9536
Practice Address - Street 1:26 EAST GRANBY RD.
Practice Address - Street 2:
Practice Address - City:GRANBY
Practice Address - State:CT
Practice Address - Zip Code:06035-0450
Practice Address - Country:US
Practice Address - Phone:860-653-7596
Practice Address - Fax:860-653-9536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty