Provider Demographics
NPI:1649618901
Name:AVON CENTER DENTISTRY
Entity type:Organization
Organization Name:AVON CENTER DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSSIERE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-404-5494
Mailing Address - Street 1:19 ENSIGN DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3705
Mailing Address - Country:US
Mailing Address - Phone:860-404-5494
Mailing Address - Fax:860-404-5582
Practice Address - Street 1:19 ENSIGN DRIVE
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001
Practice Address - Country:US
Practice Address - Phone:860-404-5494
Practice Address - Fax:860-404-5582
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEBRON CENTER DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT77531223P0300X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty