Provider Demographics
NPI:1881987964
Name:CT DENTAL LLC
Entity type:Organization
Organization Name:CT DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TULASI
Authorized Official - Middle Name:N
Authorized Official - Last Name:VIKRAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-574-2725
Mailing Address - Street 1:171 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2517
Mailing Address - Country:US
Mailing Address - Phone:203-574-2725
Mailing Address - Fax:203-574-2726
Practice Address - Street 1:171 GRANDVIEW AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2517
Practice Address - Country:US
Practice Address - Phone:203-574-2725
Practice Address - Fax:203-574-2726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-23
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1223S0112X
1223E0200X
CT0102821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty