Provider Demographics
NPI:1275806481
Name:IRVING M EDELSON DDS AND DAVID R EDELSON DMD PC
Entity Type:Organization
Organization Name:IRVING M EDELSON DDS AND DAVID R EDELSON DMD PC
Other - Org Name:DAVID R EDELSON DMD PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:EDELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-747-1004
Mailing Address - Street 1:92 EAST ST
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-2302
Mailing Address - Country:US
Mailing Address - Phone:860-747-1004
Mailing Address - Fax:860-793-2219
Practice Address - Street 1:92 EAST ST
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-2302
Practice Address - Country:US
Practice Address - Phone:860-747-1004
Practice Address - Fax:860-793-2219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-18
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006399122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT6678240001Medicare NSC