1619374881 NPI number — NORTHEAST DENTAL OF CONNECTICUT,PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619374881 NPI number — NORTHEAST DENTAL OF CONNECTICUT,PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST DENTAL OF CONNECTICUT,PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619374881
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 W CENTURY RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
PARAMUS
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07652-1450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-610-8265
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
534 SHELTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06484-2804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-610-8265
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/03/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WICKE
Authorized Official First Name:
VIRGINIA
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
732-610-8265

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  8979 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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