Provider Demographics
NPI:1316233182
Name:YANKEE FAMILY DENTAL CARE
Entity type:Organization
Organization Name:YANKEE FAMILY DENTAL CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HACKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-932-3700
Mailing Address - Street 1:267 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4405
Mailing Address - Country:US
Mailing Address - Phone:203-932-3700
Mailing Address - Fax:475-238-8291
Practice Address - Street 1:267 CENTER ST
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4405
Practice Address - Country:US
Practice Address - Phone:203-932-3700
Practice Address - Fax:475-238-8291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT71481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1871668053Medicaid