1750696399 NPI number — CONNECTICUT FAMILY DENTAL, INC

Table of content: (NPI 1750696399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750696399 NPI number — CONNECTICUT FAMILY DENTAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONNECTICUT FAMILY DENTAL, INC
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:
1750696399
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3885 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BRIDGEPORT
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06606-2814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-663-2772
Provider Business Mailing Address Fax Number:
203-275-8595

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3885 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06606-2814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-663-2772
Provider Business Practice Location Address Fax Number:
203-275-8595
Provider Enumeration Date:
08/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MENDES
Authorized Official First Name:
JACKSON
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE-PRESIDENT
Authorized Official Telephone Number:
203-663-2772

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  008314 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223X0400X , with the licence number: 10567 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





Copyright © 2007-2025 www.npivalidator.com