Provider Demographics
NPI:1043714868
Name:FAMILY DENTISTRY OF KEYPORT LLC
Entity Type:Organization
Organization Name:FAMILY DENTISTRY OF KEYPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PADILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-246-9411
Mailing Address - Street 1:90 BROOKLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-2010
Mailing Address - Country:US
Mailing Address - Phone:203-334-4837
Mailing Address - Fax:203-366-9195
Practice Address - Street 1:45 MAPLE PL
Practice Address - Street 2:
Practice Address - City:KEYPORT
Practice Address - State:NJ
Practice Address - Zip Code:07735-1358
Practice Address - Country:US
Practice Address - Phone:732-246-9411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental