Provider Demographics
NPI:1750302980
Name:DENTAL SERVICES OF SOUTH WINDSOR, LLC
Entity type:Organization
Organization Name:DENTAL SERVICES OF SOUTH WINDSOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:HAROIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-289-4955
Mailing Address - Street 1:479 BUCKLAND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-3739
Mailing Address - Country:US
Mailing Address - Phone:860-648-4471
Mailing Address - Fax:860-648-0181
Practice Address - Street 1:479 BUCKLAND ROAD
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3515
Practice Address - Country:US
Practice Address - Phone:860-648-4471
Practice Address - Fax:860-648-0181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT93001223G0001X
CT63501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty