Provider Demographics
NPI:1689997124
Name:WATERBURY FAMILY DENTAL P.C.
Entity type:Organization
Organization Name:WATERBURY FAMILY DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KANYE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BOSMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-288-3000
Mailing Address - Street 1:155 THOMASTON AVE
Mailing Address - Street 2:C12
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-1020
Mailing Address - Country:US
Mailing Address - Phone:203-288-3000
Mailing Address - Fax:203-288-3004
Practice Address - Street 1:155 THOMASTON AVE
Practice Address - Street 2:C12
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1020
Practice Address - Country:US
Practice Address - Phone:203-288-3000
Practice Address - Fax:203-288-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT010025122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty