Healthcare Provider Details

I. General information

NPI: 1891135109
Provider Name (Legal Business Name): SHORELINE DENTAL SLEEP THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 S MAIN ST
BRANFORD CT
06405-3800
US

IV. Provider business mailing address

5 S MAIN ST
BRANFORD CT
06405-3800
US

V. Phone/Fax

Practice location:
  • Phone: 203-481-3973
  • Fax: 203-488-4136
Mailing address:
  • Phone: 203-481-3973
  • Fax: 203-488-4136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5366
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number5366
License Number StateCT

VIII. Authorized Official

Name: DR. RONALD J BAILEY
Title or Position: MANAGER
Credential: DMD
Phone: 203-481-3973