Provider Demographics
NPI: | 1669795381 |
---|---|
Name: | IMPERIAL DENTAL ASSOC., PC |
Entity type: | Organization |
Organization Name: | IMPERIAL DENTAL ASSOC., PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | MARILYN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GENI-BLANEY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 203-227-2520 |
Mailing Address - Street 1: | 15 IMPERIAL AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | WESTPORT |
Mailing Address - State: | CT |
Mailing Address - Zip Code: | 06880-4302 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 203-227-2520 |
Mailing Address - Fax: | 203-454-8710 |
Practice Address - Street 1: | 15 IMPERIAL AVE |
Practice Address - Street 2: | |
Practice Address - City: | WESTPORT |
Practice Address - State: | CT |
Practice Address - Zip Code: | 06880-4302 |
Practice Address - Country: | US |
Practice Address - Phone: | 203-227-2520 |
Practice Address - Fax: | 203-454-8710 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-03-09 |
Last Update Date: | 2010-03-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CT | 008429 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |