Provider Demographics
NPI:1609916089
Name:NEW HAVEN DENTAL GROUP
Entity Type:Organization
Organization Name:NEW HAVEN DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-781-8051
Mailing Address - Street 1:123 YORK ST
Mailing Address - Street 2:SUITE 4L
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5614
Mailing Address - Country:US
Mailing Address - Phone:230-781-8051
Mailing Address - Fax:203-781-8089
Practice Address - Street 1:123 YORK ST
Practice Address - Street 2:SUITE 4L
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5614
Practice Address - Country:US
Practice Address - Phone:230-781-8051
Practice Address - Fax:203-781-8089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty