Provider Demographics
NPI:1629313077
Name:NOVA DENTAL EAST LLC
Entity Type:Organization
Organization Name:NOVA DENTAL EAST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASMA
Authorized Official - Middle Name:
Authorized Official - Last Name:IJAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-626-5745
Mailing Address - Street 1:1241 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-1737
Mailing Address - Country:US
Mailing Address - Phone:203-626-5745
Mailing Address - Fax:203-626-9213
Practice Address - Street 1:1241 S BROAD ST
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-1737
Practice Address - Country:US
Practice Address - Phone:203-626-5745
Practice Address - Fax:203-626-9213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-11
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9252122300000X, 1223G0001X, 1223S0112X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty