Provider Demographics
NPI:1801044854
Name:HAVEN PEDIATRIC DENTISTRY,LLC
Entity Type:Organization
Organization Name:HAVEN PEDIATRIC DENTISTRY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:A
Authorized Official - Last Name:VILLEGAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-933-0008
Mailing Address - Street 1:100 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-3810
Mailing Address - Country:US
Mailing Address - Phone:203-933-0008
Mailing Address - Fax:203-931-1433
Practice Address - Street 1:100 ELM ST
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-3810
Practice Address - Country:US
Practice Address - Phone:203-933-0008
Practice Address - Fax:203-931-1433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty