Provider Demographics
NPI:1932404548
Name:DENTAL ASSOCIATE GROUP LLC
Entity Type:Organization
Organization Name:DENTAL ASSOCIATE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHEIKH
Authorized Official - Middle Name:M
Authorized Official - Last Name:ILYAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-374-0000
Mailing Address - Street 1:4154 MADISON AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-3563
Mailing Address - Country:US
Mailing Address - Phone:203-374-0000
Mailing Address - Fax:203-374-0002
Practice Address - Street 1:4154 MADISON AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-3563
Practice Address - Country:US
Practice Address - Phone:203-374-0000
Practice Address - Fax:203-374-0002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0094131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty