Provider Demographics
NPI:1891244950
Name:ADULT AND PEDIATRIC DENTAL CARE OF WESTPORT,LLC
Entity Type:Organization
Organization Name:ADULT AND PEDIATRIC DENTAL CARE OF WESTPORT,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MAGD
Authorized Official - Phone:203-227-3709
Mailing Address - Street 1:22 IMPERIAL AVE
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-4301
Mailing Address - Country:US
Mailing Address - Phone:203-227-3709
Mailing Address - Fax:
Practice Address - Street 1:22 IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4301
Practice Address - Country:US
Practice Address - Phone:203-227-3709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty