Provider Demographics
NPI:1245627561
Name:NORTHEASR DENTAL OF LONG WHARF PC
Entity type:Organization
Organization Name:NORTHEASR DENTAL OF LONG WHARF PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-610-8265
Mailing Address - Street 1:1 LONG WHARF DR
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5991
Mailing Address - Country:US
Mailing Address - Phone:732-610-8265
Mailing Address - Fax:
Practice Address - Street 1:1 LONG WHARF DR
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5991
Practice Address - Country:US
Practice Address - Phone:732-610-8265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTDN20704122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty