Provider Demographics
NPI:1164517033
Name:AFFENITO, JAMES D (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:D
Last Name:AFFENITO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-5848
Mailing Address - Country:US
Mailing Address - Phone:860-589-1055
Mailing Address - Fax:
Practice Address - Street 1:391 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-5848
Practice Address - Country:US
Practice Address - Phone:860-589-1055
Practice Address - Fax:860-585-0251
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT74901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1900000704Medicare ID - Type UnspecifiedPROVIDER NUMBER