Provider Demographics
NPI:1124308184
Name:FAMILY DENTISTRY OF BRIDGEPORT P.C.
Entity type:Organization
Organization Name:FAMILY DENTISTRY OF BRIDGEPORT P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:AGABABAEV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-887-1397
Mailing Address - Street 1:90 BROOKLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-2010
Mailing Address - Country:US
Mailing Address - Phone:203-334-4837
Mailing Address - Fax:
Practice Address - Street 1:90 BROOKLAWN AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-2010
Practice Address - Country:US
Practice Address - Phone:203-334-4837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0100911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty