Provider Demographics
NPI:1720204415
Name:WEST MAIN DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:WEST MAIN DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERENCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-755-5641
Mailing Address - Street 1:1147 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2737
Mailing Address - Country:US
Mailing Address - Phone:203-755-5641
Mailing Address - Fax:
Practice Address - Street 1:1147 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2737
Practice Address - Country:US
Practice Address - Phone:203-755-5641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT43911223G0001X
NY55211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT=========OtherDENTIST