Provider Demographics
NPI:1093034621
Name:NORTHEAST DENTAL SOLUTIONS LLC
Entity Type:Organization
Organization Name:NORTHEAST DENTAL SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLIVE
Authorized Official - Middle Name:B
Authorized Official - Last Name:RUSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-338-0090
Mailing Address - Street 1:56 HARRIET ST
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06608-2131
Mailing Address - Country:US
Mailing Address - Phone:203-338-0090
Mailing Address - Fax:
Practice Address - Street 1:56 HARRIET ST
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06608-2131
Practice Address - Country:US
Practice Address - Phone:203-338-0090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009777122300000X
CT006295124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty