Provider Demographics
NPI:1578818191
Name:MAZUMDER, PRADIPTA (DDS)
Entity Type:Individual
Prefix:DR
First Name:PRADIPTA
Middle Name:
Last Name:MAZUMDER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 WATERTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2623
Mailing Address - Country:US
Mailing Address - Phone:571-594-6007
Mailing Address - Fax:
Practice Address - Street 1:109 WATERTOWN AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2623
Practice Address - Country:US
Practice Address - Phone:571-594-6007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV59901223X0400X
CT0111101223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics