Provider Demographics
NPI:1982034658
Name:FAIR HAVEN DENTAL LLC
Entity Type:Organization
Organization Name:FAIR HAVEN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:JAGINI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-306-0017
Mailing Address - Street 1:685 QUEEN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1547
Mailing Address - Country:US
Mailing Address - Phone:860-863-5831
Mailing Address - Fax:
Practice Address - Street 1:214 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-3721
Practice Address - Country:US
Practice Address - Phone:860-863-5831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-17
Last Update Date:2013-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty