Basic Information
| Provider Information | |||||||||
| NPI: | 1770572588 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UCONN HEALTH CENTER | ||||||||
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| OtherOrganizationName: | SCHOOL OF DENTAL MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | ORAL AND MAXILLOFACIAL RADIOLOGY MC 2110 | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060300001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606792453 | ||||||||
| FaxNumber: | 8606792756 | ||||||||
| Practice Location | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | ORAL AND MAXILLOFACIAL RADIOLOGY MC 2110 | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060300001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606792453 | ||||||||
| FaxNumber: | 8606792756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LURIE | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PROFESSOR | ||||||||
| AuthorizedOfficialTelephone: | 8606792453 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0008X | 004751 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2047513 | 05 | CT | MEDICAID |