Provider Demographics
NPI:1063567246
Name:AVON FAMILY DENTISTRY
Entity type:Organization
Organization Name:AVON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:COLLIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:SANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-677-6405
Mailing Address - Street 1:44 DALE RD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3612
Mailing Address - Country:US
Mailing Address - Phone:860-677-6405
Mailing Address - Fax:860-677-1189
Practice Address - Street 1:44 DALE RD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3612
Practice Address - Country:US
Practice Address - Phone:860-677-6405
Practice Address - Fax:860-677-1189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT02362921223G0001X
CT1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty