Provider Demographics
NPI:1598041154
Name:DR DENTAL OF NORWALK PC
Entity Type:Organization
Organization Name:DR DENTAL OF NORWALK PC
Other - Org Name:DR. DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:
Authorized Official - Last Name:REVECHKIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-725-0372
Mailing Address - Street 1:360 CONNECTICUT AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06854-1824
Mailing Address - Country:US
Mailing Address - Phone:201-725-0372
Mailing Address - Fax:
Practice Address - Street 1:360 CONNECTICUT AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06854-1824
Practice Address - Country:US
Practice Address - Phone:201-725-0372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0100251223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010025Medicaid