Provider Demographics
NPI:1609016963
Name:TOOTH FAIRY PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:TOOTH FAIRY PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUHO
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-403-2525
Mailing Address - Street 1:35 COPPS HILL RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-4041
Mailing Address - Country:US
Mailing Address - Phone:203-403-2525
Mailing Address - Fax:203-403-2545
Practice Address - Street 1:35 COPPS HILL RD
Practice Address - Street 2:SUITE 6
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877-4041
Practice Address - Country:US
Practice Address - Phone:203-403-2525
Practice Address - Fax:203-403-2545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-26
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X
CT1223D0004X
CT90911223P0221X
CT91351223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty