Provider Demographics
NPI:1831645167
Name:TERRYVILLE FAMILY DENTAL, LLC
Entity Type:Organization
Organization Name:TERRYVILLE FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KOSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-583-3582
Mailing Address - Street 1:14 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:TERRYVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06786-5220
Mailing Address - Country:US
Mailing Address - Phone:860-853-3582
Mailing Address - Fax:860-582-8654
Practice Address - Street 1:14 MAPLE ST
Practice Address - Street 2:
Practice Address - City:TERRYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06786-5220
Practice Address - Country:US
Practice Address - Phone:860-853-3582
Practice Address - Fax:860-582-8654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty