Provider Demographics
NPI:1922122332
Name:SIMSBURY PEDIATRIC & ADOLESCENT DENTISTRY, LLC
Entity Type:Organization
Organization Name:SIMSBURY PEDIATRIC & ADOLESCENT DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:AZADPUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-658-7548
Mailing Address - Street 1:381 HOPMEADOW ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WEATOGUE
Mailing Address - State:CT
Mailing Address - Zip Code:06089-9692
Mailing Address - Country:US
Mailing Address - Phone:860-658-7548
Mailing Address - Fax:860-658-7516
Practice Address - Street 1:381 HOPMEADOW ST
Practice Address - Street 2:SUITE 202
Practice Address - City:WEATOGUE
Practice Address - State:CT
Practice Address - Zip Code:06089-9692
Practice Address - Country:US
Practice Address - Phone:860-658-7548
Practice Address - Fax:860-658-7516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0079071223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty