Provider Demographics
NPI:1396120390
Name:WEST MAIN FAMILY DENTISTRY
Entity type:Organization
Organization Name:WEST MAIN FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST (OWNER)
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BALFOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-755-5641
Mailing Address - Street 1:1147 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2737
Mailing Address - Country:US
Mailing Address - Phone:203-755-5641
Mailing Address - Fax:203-755-1675
Practice Address - Street 1:1147 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2737
Practice Address - Country:US
Practice Address - Phone:203-755-5641
Practice Address - Fax:203-755-1675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT114031223G0001X
CT055211223G0001X
CT104931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty