| NPI | 1811480403 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHANNON MARIE GORNEAULT Billing Manager 860-610-6124 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Additional Taxonomies | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) (Licence: CT 0784) |
| 261QM0801X | |
| Enumeration Date | 2018-06-08 |
| Last Update Date | 2018-06-08 |