Provider Demographics
NPI:1518482561
Name:STRATFORD FAMILY DENTAL PC
Entity Type:Organization
Organization Name:STRATFORD FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRITIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHADKA SUBEDI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, BDS
Authorized Official - Phone:203-260-1929
Mailing Address - Street 1:112 SOUNDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-7435
Mailing Address - Country:US
Mailing Address - Phone:203-260-1929
Mailing Address - Fax:
Practice Address - Street 1:2261 BROADBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-3860
Practice Address - Country:US
Practice Address - Phone:203-375-4633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-11
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT114301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty