Provider Demographics
NPI:1598810731
Name:FAMILY DENTAL CARE LLC
Entity Type:Organization
Organization Name:FAMILY DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABDOLLAH
Authorized Official - Middle Name:
Authorized Official - Last Name:NADIMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-879-9411
Mailing Address - Street 1:503 WOLCOTT ROAD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716
Mailing Address - Country:US
Mailing Address - Phone:203-879-9411
Mailing Address - Fax:203-879-9383
Practice Address - Street 1:503 WOLCOTT ROAD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716
Practice Address - Country:US
Practice Address - Phone:203-879-9411
Practice Address - Fax:203-879-9383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008495122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002084953Medicaid