Provider Demographics
NPI:1245403187
Name:BRIDGEPORT DENTAL, LLC
Entity Type:Organization
Organization Name:BRIDGEPORT DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:CASERTA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-384-2261
Mailing Address - Street 1:633 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-1711
Mailing Address - Country:US
Mailing Address - Phone:203-384-2261
Mailing Address - Fax:203-366-4094
Practice Address - Street 1:633 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-1711
Practice Address - Country:US
Practice Address - Phone:203-384-2261
Practice Address - Fax:203-366-4094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty