Provider Demographics
NPI:1720083934
Name:WATERFORD DENTAL ASSOCIATES PC
Entity Type:Organization
Organization Name:WATERFORD DENTAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:S
Authorized Official - Last Name:CIANCIULLI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-444-0625
Mailing Address - Street 1:815 HARTFORD TPKE
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-4201
Mailing Address - Country:US
Mailing Address - Phone:860-444-0625
Mailing Address - Fax:860-442-7740
Practice Address - Street 1:815 HARTFORD TPKE
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-4201
Practice Address - Country:US
Practice Address - Phone:860-444-0625
Practice Address - Fax:860-442-7740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty