Provider Demographics
NPI:1609199074
Name:SPH ENTERPRISE LLC
Entity Type:Organization
Organization Name:SPH ENTERPRISE LLC
Other - Org Name:BRIDGEPORT FAMILY DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVRIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-873-0598
Mailing Address - Street 1:161 BOSTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-1662
Mailing Address - Country:US
Mailing Address - Phone:203-873-0598
Mailing Address - Fax:
Practice Address - Street 1:161 BOSTON AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-1662
Practice Address - Country:US
Practice Address - Phone:203-873-0598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-12
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0097851223G0001X
CT0098461223G0001X
CT0099201223G0001X
1223P0221X
CT0109461223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty