Provider Demographics
NPI:1740439645
Name:DG DENTAL CENTER LLC
Entity type:Organization
Organization Name:DG DENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:P
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-753-5041
Mailing Address - Street 1:767 WOLCOTT ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-1324
Mailing Address - Country:US
Mailing Address - Phone:203-753-5041
Mailing Address - Fax:203-753-5044
Practice Address - Street 1:767 WOLCOTT STREET
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-1324
Practice Address - Country:US
Practice Address - Phone:203-753-5041
Practice Address - Fax:203-753-5044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0083971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty