Provider Demographics
NPI:1962559245
Name:LANDESBERG, REGINA (DMD)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:LANDESBERG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:ORAL & MAXILLOFACIAL SURGERY
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-1720
Practice Address - Country:US
Practice Address - Phone:860-679-3300
Practice Address - Fax:860-679-1099
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0068551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1962559245Medicaid
CTD400002069Medicare PIN