Provider Demographics
NPI:1619362571
Name:EDWARD SHUKOVSKY
Entity Type:Organization
Organization Name:EDWARD SHUKOVSKY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUKOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-348-2411
Mailing Address - Street 1:1290 SUMMER ST
Mailing Address - Street 2:SUITE 3400
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5360
Mailing Address - Country:US
Mailing Address - Phone:203-348-2411
Mailing Address - Fax:203-348-5895
Practice Address - Street 1:1290 SUMMER ST
Practice Address - Street 2:SUITE 3400
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5360
Practice Address - Country:US
Practice Address - Phone:203-348-2411
Practice Address - Fax:203-348-5895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005762122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty