Provider Demographics
NPI:1275580870
Name:WESTPORT DENTAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:WESTPORT DENTAL ASSOCIATES, P.C.
Other - Org Name:WESTPORT DENTAL ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DUCHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-227-3709
Mailing Address - Street 1:22 IMPERIAL AVE
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-4301
Mailing Address - Country:US
Mailing Address - Phone:203-227-3709
Mailing Address - Fax:203-226-5604
Practice Address - Street 1:22 IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4301
Practice Address - Country:US
Practice Address - Phone:203-227-3709
Practice Address - Fax:203-226-5604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT51421223G0001X
CT78111223G0001X
CT36161223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty