Provider Demographics
NPI:1619374881
Name:NORTHEAST DENTAL OF CONNECTICUT,PC
Entity Type:Organization
Organization Name:NORTHEAST DENTAL OF CONNECTICUT,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-610-8265
Mailing Address - Street 1:115 W CENTURY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-1450
Mailing Address - Country:US
Mailing Address - Phone:732-610-8265
Mailing Address - Fax:
Practice Address - Street 1:534 SHELTON AVE
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-2804
Practice Address - Country:US
Practice Address - Phone:732-610-8265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8979122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty