Provider Demographics
NPI:1124881537
Name:MYORTHOS CONNECTICUT ORTHODONTICS PC
Entity type:Organization
Organization Name:MYORTHOS CONNECTICUT ORTHODONTICS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OPERATIONS & STRATEGY
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LONABOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-535-3364
Mailing Address - Street 1:126 MONROE TPKE STE K
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-1300
Mailing Address - Country:US
Mailing Address - Phone:203-590-3222
Mailing Address - Fax:
Practice Address - Street 1:2 DANIELS FARM ROAD
Practice Address - Street 2:UNITS NN25-26
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611
Practice Address - Country:US
Practice Address - Phone:203-590-3222
Practice Address - Fax:203-590-3273
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MYORTHOS CONNECTICUT ORTHODONTICS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-31
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty