Provider Demographics
NPI:1487678660
Name:KARANDISECKY, ELLEN LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:LYNN
Last Name:KARANDISECKY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4697 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1869
Mailing Address - Country:US
Mailing Address - Phone:203-372-3626
Mailing Address - Fax:203-372-4034
Practice Address - Street 1:4697 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1869
Practice Address - Country:US
Practice Address - Phone:203-372-3626
Practice Address - Fax:203-372-4034
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0064641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice