Provider Demographics
NPI:1942443726
Name:OLD LYME DENTAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:OLD LYME DENTAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:B
Authorized Official - Last Name:LAMURA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-434-7378
Mailing Address - Street 1:PO BOX 551
Mailing Address - Street 2:
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-0551
Mailing Address - Country:US
Mailing Address - Phone:860-434-7378
Mailing Address - Fax:860-434-7537
Practice Address - Street 1:19 HALLS RD
Practice Address - Street 2:SUITE 218
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371-1457
Practice Address - Country:US
Practice Address - Phone:860-434-7378
Practice Address - Fax:860-434-7537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9037261QD0000X
CT9618261QD0000X
CT9080261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental