Provider Demographics
NPI:1568013001
Name:CPDENTAL, PLLC
Entity Type:Organization
Organization Name:CPDENTAL, PLLC
Other - Org Name:SOUTHPORT FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-435-1751
Mailing Address - Street 1:10 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06890-1437
Mailing Address - Country:US
Mailing Address - Phone:203-255-5142
Mailing Address - Fax:
Practice Address - Street 1:10 JOHN ST
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:CT
Practice Address - Zip Code:06890-1437
Practice Address - Country:US
Practice Address - Phone:203-255-5142
Practice Address - Fax:203-259-5954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-26
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty