Provider Demographics
NPI: | 1790035897 |
---|---|
Name: | WESTPORT PEDIATRIC DENTISTRY |
Entity Type: | Organization |
Organization Name: | WESTPORT PEDIATRIC DENTISTRY |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | GORDON |
Authorized Official - Middle Name: | K |
Authorized Official - Last Name: | LEE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 203-226-5500 |
Mailing Address - Street 1: | 305 POST RD E |
Mailing Address - Street 2: | |
Mailing Address - City: | WESTPORT |
Mailing Address - State: | CT |
Mailing Address - Zip Code: | 06880-3613 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 203-226-5500 |
Mailing Address - Fax: | 203-226-5501 |
Practice Address - Street 1: | 305 POST RD E |
Practice Address - Street 2: | |
Practice Address - City: | WESTPORT |
Practice Address - State: | CT |
Practice Address - Zip Code: | 06880-3613 |
Practice Address - Country: | US |
Practice Address - Phone: | 203-226-5500 |
Practice Address - Fax: | 203-226-5501 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-09-16 |
Last Update Date: | 2012-09-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CT | 10577 | 1223P0221X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223P0221X | Dental Providers | Dentist | Pediatric Dentistry | Group - Single Specialty |