Provider Demographics
NPI:1861919409
Name:P & L VENTURE LLC
Entity type:Organization
Organization Name:P & L VENTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LON
Authorized Official - Middle Name:
Authorized Official - Last Name:POLVERARI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-596-1960
Mailing Address - Street 1:835 WOLCOTT ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-1315
Mailing Address - Country:US
Mailing Address - Phone:203-596-1960
Mailing Address - Fax:203-596-1998
Practice Address - Street 1:102 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3233
Practice Address - Country:US
Practice Address - Phone:203-596-1960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007375261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental