Provider Demographics
NPI:1750696399
Name:CONNECTICUT FAMILY DENTAL, INC
Entity type:Organization
Organization Name:CONNECTICUT FAMILY DENTAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-663-2772
Mailing Address - Street 1:3885 MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-2814
Mailing Address - Country:US
Mailing Address - Phone:203-663-2772
Mailing Address - Fax:203-275-8595
Practice Address - Street 1:3885 MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-2814
Practice Address - Country:US
Practice Address - Phone:203-663-2772
Practice Address - Fax:203-275-8595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-06
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT105671223X0400X
CT0083141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty