Provider Demographics
NPI:1174038327
Name:FIRST DENTAL LLC
Entity Type:Organization
Organization Name:FIRST DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHANG HYUN
Authorized Official - Middle Name:
Authorized Official - Last Name:NA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-292-5753
Mailing Address - Street 1:325 REEF RD STE 106
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:325 REEF RD STE 106
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6537
Practice Address - Country:US
Practice Address - Phone:203-292-5753
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008025885Medicaid