Provider Demographics
NPI:1417200932
Name:COMPASSION DENTAL 06032 LLC
Entity type:Organization
Organization Name:COMPASSION DENTAL 06032 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIEDERICH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-470-3660
Mailing Address - Street 1:218 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-3623
Mailing Address - Country:US
Mailing Address - Phone:860-470-3660
Mailing Address - Fax:860-404-5642
Practice Address - Street 1:218 MAIN STREET
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-3623
Practice Address - Country:US
Practice Address - Phone:860-470-3660
Practice Address - Fax:860-404-5642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7122261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental