Provider Demographics
NPI:1396209219
Name:JETAS DENTAL
Entity Type:Organization
Organization Name:JETAS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIS
Authorized Official - Prefix:
Authorized Official - First Name:JETA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZEDEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-262-8051
Mailing Address - Street 1:1449 OLD WATERBURY RD
Mailing Address - Street 2:UNIT 202, ONE RESERVOIR PARK
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-3926
Mailing Address - Country:US
Mailing Address - Phone:203-262-8051
Mailing Address - Fax:203-262-8956
Practice Address - Street 1:1449 OLD WATERBURY RD
Practice Address - Street 2:UNIT 202, ONE RESERVOIR PARK
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-3926
Practice Address - Country:US
Practice Address - Phone:203-262-8051
Practice Address - Fax:203-262-8956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty