Provider Demographics
NPI:1700981602
Name:FAMILY DENTAL GROUP C.A.
Entity Type:Organization
Organization Name:FAMILY DENTAL GROUP C.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:V
Authorized Official - Last Name:MUNK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-337-6266
Mailing Address - Street 1:468 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-1713
Mailing Address - Country:US
Mailing Address - Phone:203-337-6266
Mailing Address - Fax:203-337-6261
Practice Address - Street 1:468 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-1713
Practice Address - Country:US
Practice Address - Phone:203-337-6266
Practice Address - Fax:203-337-6261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0066701223G0001X
1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004163002Medicaid
CT008008008Medicaid