Provider Demographics
NPI:1841486610
Name:WESTFARMS MALL DENTAL L.L.P
Entity type:Organization
Organization Name:WESTFARMS MALL DENTAL L.L.P
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSTISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASNOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-676-2828
Mailing Address - Street 1:213 WESTFARMS MALL
Mailing Address - Street 2:SUITE 204A
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2633
Mailing Address - Country:US
Mailing Address - Phone:860-676-2828
Mailing Address - Fax:
Practice Address - Street 1:213 WESTFARMS MALL
Practice Address - Street 2:SUITE 204A
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2615
Practice Address - Country:US
Practice Address - Phone:860-676-2828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0086981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty