Provider Demographics
NPI:1447646757
Name:COMPREHENSIVE AESTHETIC DENTISTRY PC
Entity type:Organization
Organization Name:COMPREHENSIVE AESTHETIC DENTISTRY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-232-4511
Mailing Address - Street 1:901 FARMINGTON AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1418
Mailing Address - Country:US
Mailing Address - Phone:860-232-4511
Mailing Address - Fax:860-236-0482
Practice Address - Street 1:901 FARMINGTON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1418
Practice Address - Country:US
Practice Address - Phone:860-232-4511
Practice Address - Fax:860-236-0482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5869122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty