Provider Demographics
NPI:1811486517
Name:DIRECT DENTAL SERVICES LLC
Entity type:Organization
Organization Name:DIRECT DENTAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EMIL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-890-9191
Mailing Address - Street 1:70 MILL RIVER ST STE UL2
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3725
Mailing Address - Country:US
Mailing Address - Phone:203-890-9191
Mailing Address - Fax:203-890-9193
Practice Address - Street 1:70 MILL RIVER ST STE UL2
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3725
Practice Address - Country:US
Practice Address - Phone:203-890-9191
Practice Address - Fax:203-890-9193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT119541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT=========Medicaid