Provider Demographics
NPI:1831966936
Name:GORGEOUS SMILES DENTAL SOUTHINGTON
Entity type:Organization
Organization Name:GORGEOUS SMILES DENTAL SOUTHINGTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BELISLE
Authorized Official - Suffix:
Authorized Official - Credentials:COO
Authorized Official - Phone:860-978-3294
Mailing Address - Street 1:775 QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1531
Mailing Address - Country:US
Mailing Address - Phone:860-965-5995
Mailing Address - Fax:
Practice Address - Street 1:775 QUEEN ST
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-1531
Practice Address - Country:US
Practice Address - Phone:860-965-5995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GORGEOUS SMILES SOUTHINGTON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-12-08
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty