Provider Demographics
NPI:1659624393
Name:ELM STREET DENTAL
Entity Type:Organization
Organization Name:ELM STREET DENTAL
Other - Org Name:DENTAL SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DHARAM
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-239-5889
Mailing Address - Street 1:1100 BARNUM AVE
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-4901
Mailing Address - Country:US
Mailing Address - Phone:716-239-5889
Mailing Address - Fax:
Practice Address - Street 1:1100 BARNUM AVE
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-4901
Practice Address - Country:US
Practice Address - Phone:716-239-5889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-18
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT010825122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty