Provider Demographics
NPI:1477893543
Name:HERGOTT DENTAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:HERGOTT DENTAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:HERGOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-235-3738
Mailing Address - Street 1:166 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-6524
Mailing Address - Country:US
Mailing Address - Phone:203-235-3738
Mailing Address - Fax:
Practice Address - Street 1:166 S BROAD ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-6524
Practice Address - Country:US
Practice Address - Phone:203-235-3738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty