Organization
BLUE BACK DENTAL LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KIRSTEN E CAPOZZI (PRACTICE MANAGER)
(860) 233-9300
Entity
Organization
Contact information
Practice address
65 MEMORIAL RD STE 400, WEST HARTFORD, CT 06107-4219
(860) 233-9300
(860) 233-9304
Mailing address
65 MEMORIAL RD STE 400, WEST HARTFORD, CT 06107-4219
(860) 233-9300
(860) 233-9304
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
5904
CT
1223G0001X
General Practice Dentistry
8915
CT
1223P0300X
Periodontics
5407
CT
Other
Enumeration date
04/20/2011
Last updated
04/20/2011
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