Provider Demographics
NPI:1033510474
Name:PEARL DENTAL OF STAMFORD, PC
Entity Type:Organization
Organization Name:PEARL DENTAL OF STAMFORD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAVEETA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANNAMSETTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-325-2102
Mailing Address - Street 1:1055 SUMMER ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5527
Mailing Address - Country:US
Mailing Address - Phone:203-325-2102
Mailing Address - Fax:203-325-1153
Practice Address - Street 1:1055 SUMMER ST
Practice Address - Street 2:SUITE 3
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5527
Practice Address - Country:US
Practice Address - Phone:203-325-2102
Practice Address - Fax:203-325-1153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0098371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty