Provider Demographics
NPI:1750414488
Name:DRYSGULA FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:DRYSGULA FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:DRYSGULA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-347-6100
Mailing Address - Street 1:775 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2903
Mailing Address - Country:US
Mailing Address - Phone:860-347-6100
Mailing Address - Fax:860-347-3095
Practice Address - Street 1:775 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-2903
Practice Address - Country:US
Practice Address - Phone:860-347-6100
Practice Address - Fax:860-347-3095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty