Provider Demographics
NPI:1568700920
Name:BRASS CITY DENTISTRY
Entity Type:Organization
Organization Name:BRASS CITY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BILAL
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-437-3221
Mailing Address - Street 1:211 POMEROY AVE
Mailing Address - Street 2:UNIT 1102
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-7165
Mailing Address - Country:US
Mailing Address - Phone:317-437-3221
Mailing Address - Fax:
Practice Address - Street 1:3670 E MAIN ST
Practice Address - Street 2:SUITE 10
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-3851
Practice Address - Country:US
Practice Address - Phone:203-754-0184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-19
Last Update Date:2013-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0107511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008040725Medicaid
CT008040721Medicaid