Provider Demographics
NPI:1295028942
Name:WEST MAIN DENTAL LLC
Entity Type:Organization
Organization Name:WEST MAIN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KHURRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ASGHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-939-1460
Mailing Address - Street 1:87 W MAIN ST
Mailing Address - Street 2:UNIT 105A
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06051-2216
Mailing Address - Country:US
Mailing Address - Phone:203-939-1460
Mailing Address - Fax:
Practice Address - Street 1:87 W MAIN ST
Practice Address - Street 2:UNIT 105A
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-2216
Practice Address - Country:US
Practice Address - Phone:203-939-1460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT103421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty