Provider Demographics
NPI:1376953356
Name:MERIDEN ADULT AND CHILDREN'S PC
Entity Type:Organization
Organization Name:MERIDEN ADULT AND CHILDREN'S PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASST
Authorized Official - Prefix:MS
Authorized Official - First Name:ELBA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-690-9687
Mailing Address - Street 1:415 BROAD ST
Mailing Address - Street 2:MERIDEN ADULT AND CHILDREN PC
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-9999
Mailing Address - Country:US
Mailing Address - Phone:203-690-9687
Mailing Address - Fax:
Practice Address - Street 1:415 BROAD ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-9999
Practice Address - Country:US
Practice Address - Phone:203-690-9687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT17203728401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1720372840Medicaid