Provider Demographics
NPI:1942808084
Name:ADVANCED DENTAL OF WALLINGFORD LLC
Entity Type:Organization
Organization Name:ADVANCED DENTAL OF WALLINGFORD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-591-5434
Mailing Address - Street 1:910 BOSTON POST RD OFC
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-1845
Mailing Address - Country:US
Mailing Address - Phone:713-591-5434
Mailing Address - Fax:
Practice Address - Street 1:44 FAIR ST
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-4214
Practice Address - Country:US
Practice Address - Phone:713-591-5434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental