Provider Demographics
NPI:1134477532
Name:SHORELINE MODERN DENTAL LLC
Entity Type:Organization
Organization Name:SHORELINE MODERN DENTAL LLC
Other - Org Name:SHORELINE MODERN DENTAL LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-395-5200
Mailing Address - Street 1:191 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2392
Mailing Address - Country:US
Mailing Address - Phone:860-395-5200
Mailing Address - Fax:
Practice Address - Street 1:191 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2392
Practice Address - Country:US
Practice Address - Phone:860-395-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-16
Last Update Date:2016-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty