Provider Demographics
NPI:1457420770
Name:CONNECTICUT DENTAL GROUPS
Entity Type:Organization
Organization Name:CONNECTICUT DENTAL GROUPS
Other - Org Name:GROTON DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUCY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-456-3153
Mailing Address - Street 1:1100 POQUONNOCK RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340
Mailing Address - Country:US
Mailing Address - Phone:860-445-9765
Mailing Address - Fax:860-445-2757
Practice Address - Street 1:1100 POQUONNOCK RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340
Practice Address - Country:US
Practice Address - Phone:860-445-9765
Practice Address - Fax:860-445-2757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty