Provider Demographics
NPI:1336570357
Name:EVERGREEN PROSTHODONTIC ASSOCIATES, LLC
Entity Type:Organization
Organization Name:EVERGREEN PROSTHODONTIC ASSOCIATES, LLC
Other - Org Name:SOUTHBURY SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:NA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-264-1620
Mailing Address - Street 1:2 POMPERAUG OFFICE PARK STE 304
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2288
Mailing Address - Country:US
Mailing Address - Phone:203-264-1620
Mailing Address - Fax:
Practice Address - Street 1:2 POMPERAUG OFFICE PARK STE 304
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2288
Practice Address - Country:US
Practice Address - Phone:203-264-1620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVERGREEN PROSTHODONTIC ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-01
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223P0700X
CT102171223G0001X
CT98631223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty