Provider Demographics
NPI:1730175845
Name:DERMATOLOGY ASSOCIATES OF GLASTONBURY LLC
Entity type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF GLASTONBURY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JANELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-633-1543
Mailing Address - Street 1:210 NEW LONDON TPKE
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2235
Mailing Address - Country:US
Mailing Address - Phone:860-633-1543
Mailing Address - Fax:860-659-9755
Practice Address - Street 1:210 NEW LONDON TPKE
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2235
Practice Address - Country:US
Practice Address - Phone:860-633-1543
Practice Address - Fax:860-659-9755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC01884Medicare PIN