Provider Demographics
NPI:1457493728
Name:UNIVERSITY OF BRIDGEPORT
Entity Type:Organization
Organization Name:UNIVERSITY OF BRIDGEPORT
Other - Org Name:FONES SCHOOL OF DENTAL HYGIENE DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V. P. ADMINISTRATION AND FINANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-576-4651
Mailing Address - Street 1:60 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-7719
Mailing Address - Country:US
Mailing Address - Phone:203-576-4138
Mailing Address - Fax:203-576-4220
Practice Address - Street 1:60 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-7719
Practice Address - Country:US
Practice Address - Phone:203-576-4138
Practice Address - Fax:203-576-4220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0463261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004010955Medicaid