Provider Demographics
NPI:1619061504
Name:JOHN A DUDLEY DMD AND DEIDER M CONDON DMD LLC
Entity Type:Organization
Organization Name:JOHN A DUDLEY DMD AND DEIDER M CONDON DMD LLC
Other - Org Name:LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-426-0045
Mailing Address - Street 1:172 MT PLEASANT RD
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470
Mailing Address - Country:US
Mailing Address - Phone:203-426-0045
Mailing Address - Fax:203-270-1555
Practice Address - Street 1:172 MT PLEASANT RD
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470
Practice Address - Country:US
Practice Address - Phone:203-426-0045
Practice Address - Fax:203-270-1555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT55761223G0001X
CT83041223G0001X
CT90041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty