NPIMap

Organization Active NPI

Blue Back Dental LLC

  • General Practice Dentistry
  • West Hartford, CT
National Provider Identifier
1174814495
Registry record updated Apr 20, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
5904 Issued in CT
Legal business name
BLUE BACK DENTAL LLC
Practice address
65 Memorial Rd Ste 400
West Hartford, CT 06107-4219
Phone
(860) 233-9300
Fax
(860) 233-9304
NPI assigned
Apr 20, 2011
Last updated
Apr 20, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 20, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kirsten E Capozzi
Title
Practice Manager
Phone
(860) 233-9300

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Dentistry 1223G0001X 8915 CT
General Practice Dentistry 1223G0001X 5904 CT Primary
Periodontics 1223P0300X 5407 CT

Addresses

Primary practice location

65 Memorial Rd Ste 400
West Hartford, CT 06107-4219

Mailing address

65 Memorial Rd Ste 400
West Hartford, CT 06107-4219
Phone (860) 233-9300

National Provider Directory

National Provider Directory

Locations

65 Memorial Rd
Ste 400
West Hartford, CT 06107
Phone (860) 233-9300

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1303257600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1303257600000",
    "number": "1174814495",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "65 MEMORIAL RD STE 400",
            "city": "WEST HARTFORD",
            "state": "CT",
            "postal_code": "061074219",
            "telephone_number": "860-233-9300",
            "fax_number": "860-233-9304"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "65 MEMORIAL RD STE 400",
            "city": "WEST HARTFORD",
            "state": "CT",
            "postal_code": "061074219",
            "telephone_number": "860-233-9300",
            "fax_number": "860-233-9304"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLUE BACK DENTAL LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-04-20",
        "last_updated": "2011-04-20",
        "status": "A",
        "authorized_official_last_name": "CAPOZZI",
        "authorized_official_first_name": "KIRSTEN",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "PRACTICE MANAGER",
        "authorized_official_telephone_number": "860-233-9300"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "CT",
            "license": "8915",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "CT",
            "license": "5904",
            "primary": true
        },
        {
            "code": "1223P0300X",
            "taxonomy_group": "",
            "desc": "Dentist, Periodontics",
            "state": "CT",
            "license": "5407",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in West Hartford, CT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 20, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.