Provider Demographics
NPI:1770572588
Name:UCONN HEALTH CENTER
Entity type:Organization
Organization Name:UCONN HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROFESSOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:LURIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-679-2453
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:ORAL AND MAXILLOFACIAL RADIOLOGY MC 2110
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-0001
Mailing Address - Country:US
Mailing Address - Phone:860-679-2453
Mailing Address - Fax:860-679-2756
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:ORAL AND MAXILLOFACIAL RADIOLOGY MC 2110
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-2453
Practice Address - Fax:860-679-2756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0047511223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2047513Medicaid
CTU28042Medicare UPIN