Organization
CREST FAMILY DENTAL, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SHYAM SHIVAREDDY (MANAGER)
(904) 514-1217
Entity
Organization
Contact information
Practice address
85 SEYMOUR ST, SUITE 1018, HARTFORD, CT 06106-5501
(860) 251-6999
(860) 251-6997
Mailing address
85 SEYMOUR ST, SUITE 1018, HARTFORD, CT 06106-5501
(860) 251-6999
(860) 251-6997
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
CT10690
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1223G0001X
—
CT
Enumeration date
05/05/2014
Last updated
05/05/2014
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