Provider Demographics
NPI:1912249517
Name:DR.DENTAL OF DERBY P.C.
Entity Type:Organization
Organization Name:DR.DENTAL OF DERBY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:
Authorized Official - Last Name:REVECHKIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-725-0372
Mailing Address - Street 1:49 PERSHING DR
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:49 PERSHING DR
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1406
Practice Address - Country:US
Practice Address - Phone:201-725-0372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-21
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0100251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010025Medicaid