Provider Demographics
NPI:1679746093
Name:ELM FAMILY DENTAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:ELM FAMILY DENTAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-933-2223
Mailing Address - Street 1:233 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4635
Mailing Address - Country:US
Mailing Address - Phone:203-933-2223
Mailing Address - Fax:203-933-2220
Practice Address - Street 1:233 ELM ST
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4635
Practice Address - Country:US
Practice Address - Phone:203-933-2223
Practice Address - Fax:203-933-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0087551223G0001X
CT0097601223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty