Provider Demographics
NPI:1568720613
Name:SOARES, CHRISTOPHER VIJAY
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:VIJAY
Last Name:SOARES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 CANDLEWOOD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-2226
Mailing Address - Country:US
Mailing Address - Phone:203-300-1394
Mailing Address - Fax:
Practice Address - Street 1:128 CANDLEWOOD LAKE RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-2226
Practice Address - Country:US
Practice Address - Phone:203-300-1394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT110071223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice