Basic Information
Provider Information | |||||||||
NPI: | 1720088917 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SOBANSKI | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | BRIAN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 40 MANSFIELD AVE | ||||||||
Address2: |   | ||||||||
City: | WILLIMANTIC | ||||||||
State: | CT | ||||||||
PostalCode: | 062262018 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8604507471 | ||||||||
FaxNumber: | 8604509808 | ||||||||
Practice Location | |||||||||
Address1: | 131 NEW LONDON TPKE | ||||||||
Address2: | SUITE 211 | ||||||||
City: | GLASTONBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 060332246 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606330486 | ||||||||
FaxNumber: | 8606592126 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2005 | ||||||||
LastUpdateDate: | 07/01/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 8556 | CT | Y |   | Dental Providers | Dentist | General Practice | 122300000X | 8556 | CT | N |   | Dental Providers | Dentist |   |
No ID Information.