Provider Demographics
NPI:1164643961
Name:DUSTIN DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:DUSTIN DENTAL ASSOCIATES, LLC
Other - Org Name:DUSTIN ORTHODONTICS
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SHARPE
Authorized Official - Last Name:DUSTIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD, MSD
Authorized Official - Phone:203-869-8711
Mailing Address - Street 1:90 DEARFIELD DR
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06831-5349
Mailing Address - Country:US
Mailing Address - Phone:203-869-8711
Mailing Address - Fax:
Practice Address - Street 1:68 DEARFIELD DR
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06831-5350
Practice Address - Country:US
Practice Address - Phone:203-869-8711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT76821223G0001X
CT70701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty