Provider Demographics
NPI:1467754309
Name:CT BRACES, LLC
Entity Type:Organization
Organization Name:CT BRACES, LLC
Other - Org Name:BRIDGEPORT ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-374-1911
Mailing Address - Street 1:3741 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-3609
Mailing Address - Country:US
Mailing Address - Phone:203-374-1911
Mailing Address - Fax:
Practice Address - Street 1:3741 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606
Practice Address - Country:US
Practice Address - Phone:203-374-1911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1922271550Medicaid