Provider Demographics
NPI:1023446093
Name:LIFE LONG DENTAL CARE OF NORTHFORD LLC
Entity type:Organization
Organization Name:LIFE LONG DENTAL CARE OF NORTHFORD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-484-0456
Mailing Address - Street 1:1355 MIDDLETOWN AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06472-1382
Mailing Address - Country:US
Mailing Address - Phone:203-484-0456
Mailing Address - Fax:203-484-4050
Practice Address - Street 1:1355 MIDDLETOWN AVE
Practice Address - Street 2:
Practice Address - City:NORTHFORD
Practice Address - State:CT
Practice Address - Zip Code:06472-1382
Practice Address - Country:US
Practice Address - Phone:203-484-0456
Practice Address - Fax:203-484-4050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty