Provider Demographics
NPI:1336370006
Name:ROUTE 67 FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ROUTE 67 FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:M
Authorized Official - Middle Name:ANITA
Authorized Official - Last Name:BLUME
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-888-7944
Mailing Address - Street 1:276 BANK ST
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:CT
Mailing Address - Zip Code:06483-2700
Mailing Address - Country:US
Mailing Address - Phone:203-888-7944
Mailing Address - Fax:203-888-5397
Practice Address - Street 1:276 BANK ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:CT
Practice Address - Zip Code:06483-2700
Practice Address - Country:US
Practice Address - Phone:203-888-7944
Practice Address - Fax:203-888-5397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-29
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0065781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1508905464OtherINDIVIDUAL NPI NUMBER