Provider Demographics
NPI:1376789966
Name:FAMILY DENTAL PRACTICE PC
Entity Type:Organization
Organization Name:FAMILY DENTAL PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONCHAROVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-353-8532
Mailing Address - Street 1:316 HOPE ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06906-1704
Mailing Address - Country:US
Mailing Address - Phone:203-353-8532
Mailing Address - Fax:203-353-8542
Practice Address - Street 1:316 HOPE ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06906-1704
Practice Address - Country:US
Practice Address - Phone:203-353-8532
Practice Address - Fax:203-353-8542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-02
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0089841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002089846Medicaid