Individual
ELLEN EISENBERG
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DMD
Contact information
Practice address
263 FARMINGTON AVE, FARMINGTON, CT 06030-0001
(860) 679-2952
(860) 679-4760
Mailing address
263 FARMINGTON AVE, PROVIDER ENROLLMENT, FARMINGTON, CT 06030-2212
(860) 679-7503
(860) 679-1610
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
005451
CT
1223P0106X
Oral and Maxillofacial Pathology Dentistry
Primary
005451
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2054518
—
CT
Enumeration date
06/22/2005
Last updated
09/28/2022
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