Provider Demographics
NPI:1336699396
Name:DRIESMAN ORTHODONTICS
Entity Type:Organization
Organization Name:DRIESMAN ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASARELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-276-1586
Mailing Address - Street 1:24 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:203-227-6061
Mailing Address - Fax:
Practice Address - Street 1:24 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:203-227-6061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0108751223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty