Provider Demographics
NPI:1487872883
Name:ORAL CARE DENTAL GROUP II, LLC
Entity type:Organization
Organization Name:ORAL CARE DENTAL GROUP II, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTA MARIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-447-9280
Mailing Address - Street 1:21 MONTAUK AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4906
Mailing Address - Country:US
Mailing Address - Phone:860-447-9280
Mailing Address - Fax:860-437-1938
Practice Address - Street 1:21 MONTAUK AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4906
Practice Address - Country:US
Practice Address - Phone:860-447-9280
Practice Address - Fax:860-437-1938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004249076Medicaid