Provider Demographics
NPI:1295187821
Name:A VANDIVEER STRAIT JR
Entity Type:Organization
Organization Name:A VANDIVEER STRAIT JR
Other - Org Name:WILTON DENTAL ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:A
Authorized Official - Middle Name:VANDIVEER
Authorized Official - Last Name:STRAIT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-761-0223
Mailing Address - Street 1:44 OLD RIDGEFIELD RD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-3055
Mailing Address - Country:US
Mailing Address - Phone:203-761-0223
Mailing Address - Fax:
Practice Address - Street 1:44 OLD RIDGEFIELD RD
Practice Address - Street 2:SUITE 212
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-3055
Practice Address - Country:US
Practice Address - Phone:203-761-0223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT38491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty