Provider Demographics
NPI:1104187673
Name:DR.DENTAL OF NEW HAVEN, PC
Entity Type:Organization
Organization Name:DR.DENTAL OF NEW HAVEN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAYNE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BOSMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-671-8949
Mailing Address - Street 1:122 AMITY ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06515
Mailing Address - Country:US
Mailing Address - Phone:203-671-8949
Mailing Address - Fax:203-288-3004
Practice Address - Street 1:122 AMITY ROAD
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06515
Practice Address - Country:US
Practice Address - Phone:203-671-8949
Practice Address - Fax:203-288-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008007943Medicaid