Provider Demographics
NPI:1982759791
Name:PEDIATRIC DENTISTRY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:B
Authorized Official - Last Name:KECK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-787-3669
Mailing Address - Street 1:149 DURHAM RD STE 33
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-2680
Mailing Address - Country:US
Mailing Address - Phone:203-245-1454
Mailing Address - Fax:203-245-8998
Practice Address - Street 1:149 DURHAM RD STE 33
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-2680
Practice Address - Country:US
Practice Address - Phone:203-245-1454
Practice Address - Fax:203-245-8998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT55251223P0221X
CT78141223P0221X
CT94091223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1710988704OtherINDIVIDUAL NPI
CT1760569685OtherINDIVIDUAL NPI
CT1184624058OtherINDIVIDUAL NPI