Healthcare Provider Details

I. General information

NPI: 1750696399
Provider Name (Legal Business Name): CONNECTICUT FAMILY DENTAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3885 MAIN ST SUITE 101
BRIDGEPORT CT
06606-2814
US

IV. Provider business mailing address

3885 MAIN ST SUITE 101
BRIDGEPORT CT
06606-2814
US

V. Phone/Fax

Practice location:
  • Phone: 203-663-2772
  • Fax: 203-275-8595
Mailing address:
  • Phone: 203-663-2772
  • Fax: 203-275-8595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number008314
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number10567
License Number StateCT

VIII. Authorized Official

Name: MR. JACKSON MENDES
Title or Position: VICE-PRESIDENT
Credential:
Phone: 203-663-2772