Provider Demographics
NPI:1629225875
Name:PEDIATRIC DENTAL ASSOCIATES OF SOUTHBURY LLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL ASSOCIATES OF SOUTHBURY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARGUERITE
Authorized Official - Middle Name:C
Authorized Official - Last Name:GILLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-264-1497
Mailing Address - Street 1:1 POMPERAUG OFFICE PARK
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2295
Mailing Address - Country:US
Mailing Address - Phone:203-264-1497
Mailing Address - Fax:203-264-4039
Practice Address - Street 1:1 POMPERAUG OFFICE PARK
Practice Address - Street 2:SUITE 206
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2295
Practice Address - Country:US
Practice Address - Phone:203-264-1497
Practice Address - Fax:203-264-4039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0078341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008001055Medicaid