Provider Demographics
NPI:1194849356
Name:SOUTHERN CONNECTICUT DENTAL GROUP PC
Entity Type:Organization
Organization Name:SOUTHERN CONNECTICUT DENTAL GROUP PC
Other - Org Name:DWORKIN & STEIN DENTAL GROUP PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:STEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-735-4701
Mailing Address - Street 1:497 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANSONIA
Mailing Address - State:CT
Mailing Address - Zip Code:06401-2308
Mailing Address - Country:US
Mailing Address - Phone:203-735-4701
Mailing Address - Fax:203-736-9443
Practice Address - Street 1:497 MAIN ST
Practice Address - Street 2:
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401-2308
Practice Address - Country:US
Practice Address - Phone:203-735-4701
Practice Address - Fax:203-736-9443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT58801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT7313430001Medicare NSC