Provider Demographics
NPI:1760431621
Name:NOVA DENTAL LLC
Entity Type:Organization
Organization Name:NOVA DENTAL 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:203-234-3900
Mailing Address - Street 1:521 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-1312
Mailing Address - Country:US
Mailing Address - Phone:203-234-3900
Mailing Address - Fax:203-234-3941
Practice Address - Street 1:521 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-1312
Practice Address - Country:US
Practice Address - Phone:203-234-3900
Practice Address - Fax:203-234-3941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9252122300000X, 1223G0001X, 1223P0700X, 1223S0112X, 1223X0400X
CT104781223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty