Provider Demographics
NPI:1154191864
Name:SPARKS FAMILY DENTAL PLLC
Entity type:Organization
Organization Name:SPARKS FAMILY DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER/GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-633-1809
Mailing Address - Street 1:622 HEBRON AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-5003
Mailing Address - Country:US
Mailing Address - Phone:860-633-1809
Mailing Address - Fax:
Practice Address - Street 1:622 HEBRON AVE STE 105
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-5003
Practice Address - Country:US
Practice Address - Phone:860-633-1809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental