Provider Demographics
NPI:1609311604
Name:EAST HAMPTON FAMILY DENTAL
Entity Type:Organization
Organization Name:EAST HAMPTON FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIJAYALAKSHMI
Authorized Official - Middle Name:
Authorized Official - Last Name:CANAKALAVENKATA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-267-9904
Mailing Address - Street 1:41 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:CT
Mailing Address - Zip Code:06424-1024
Mailing Address - Country:US
Mailing Address - Phone:860-267-9904
Mailing Address - Fax:860-267-7270
Practice Address - Street 1:41 W HIGH ST
Practice Address - Street 2:
Practice Address - City:EAST HAMPTON
Practice Address - State:CT
Practice Address - Zip Code:06424-1024
Practice Address - Country:US
Practice Address - Phone:860-267-9904
Practice Address - Fax:860-267-7270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT113461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty