Provider Demographics
NPI:1548635899
Name:CHARTER OAK DENTAL CENTER LLC
Entity type:Organization
Organization Name:CHARTER OAK DENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAKIL
Authorized Official - Middle Name:U
Authorized Official - Last Name:SYED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-899-2804
Mailing Address - Street 1:330 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-1860
Mailing Address - Country:US
Mailing Address - Phone:860-899-2804
Mailing Address - Fax:860-899-2803
Practice Address - Street 1:330 MAIN ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1860
Practice Address - Country:US
Practice Address - Phone:860-899-2804
Practice Address - Fax:860-899-2803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11063122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT11063OtherCONNECTICUT DENTAL LICENSE NUMBER