Provider Demographics
NPI:1780930263
Name:NORTH AVENUE ADVANCED DENTAL CENTER
Entity type:Organization
Organization Name:NORTH AVENUE ADVANCED DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:BREA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-853-2732
Mailing Address - Street 1:2260 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-2413
Mailing Address - Country:US
Mailing Address - Phone:203-853-2732
Mailing Address - Fax:203-612-9781
Practice Address - Street 1:2260 NORTH AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-2413
Practice Address - Country:US
Practice Address - Phone:203-853-2732
Practice Address - Fax:203-612-9781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty