Provider Demographics
NPI:1235719378
Name:SUPREME DENTAL, LLC
Entity Type:Organization
Organization Name:SUPREME DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMADREZA
Authorized Official - Middle Name:
Authorized Official - Last Name:GHORBANIPARVAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-348-5612
Mailing Address - Street 1:44 STRAWBERRY HILL AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-2632
Mailing Address - Country:US
Mailing Address - Phone:774-345-9799
Mailing Address - Fax:
Practice Address - Street 1:44 STRAWBERRY HILL AVE STE 9
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-2632
Practice Address - Country:US
Practice Address - Phone:774-345-9799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-13
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental