Provider Demographics
NPI:1518354380
Name:NEW HAVEN FAMILY DENTAL
Entity Type:Organization
Organization Name:NEW HAVEN FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:LAKSHMI
Authorized Official - Middle Name:
Authorized Official - Last Name:BETHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-421-7576
Mailing Address - Street 1:55 FOX HOLLOW DRIVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR LOCKS
Mailing Address - State:CT
Mailing Address - Zip Code:06096
Mailing Address - Country:US
Mailing Address - Phone:215-421-7576
Mailing Address - Fax:
Practice Address - Street 1:214 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513
Practice Address - Country:US
Practice Address - Phone:215-421-7576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-20
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0109301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010930OtherGENERAL DENTIST