Provider Demographics
NPI:1104162890
Name:BLOOMFIELD FAMILY DENTAL PC
Entity type:Organization
Organization Name:BLOOMFIELD FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARI
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-656-6941
Mailing Address - Street 1:2 WINTONBURY MALL
Mailing Address - Street 2:#5
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-2466
Mailing Address - Country:US
Mailing Address - Phone:860-656-6941
Mailing Address - Fax:860-656-6107
Practice Address - Street 1:2 WINTONBURY MALL
Practice Address - Street 2:#5
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2466
Practice Address - Country:US
Practice Address - Phone:860-656-6941
Practice Address - Fax:860-656-6107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-27
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0092981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1962684415Medicaid