1558687103 NPI number — SPH2 ENTERPRISE LLC

Table of content: (NPI 1558687103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558687103 NPI number — SPH2 ENTERPRISE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPH2 ENTERPRISE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MERIDEN FAMILY DENTAL GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558687103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
553 PORTLAND COBALT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06480-1968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-342-4141
Provider Business Mailing Address Fax Number:
860-342-1284

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
470 LEWIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06451-2103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-342-4141
Provider Business Practice Location Address Fax Number:
860-342-1284
Provider Enumeration Date:
04/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DEVRIES
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
860-342-4141

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  009785 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 009846 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 009920 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0106X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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