Healthcare Provider Details

I. General information

NPI: 1780930263
Provider Name (Legal Business Name): NORTH AVENUE ADVANCED DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2260 NORTH AVE
BRIDGEPORT CT
06604-2413
US

IV. Provider business mailing address

2260 NORTH AVE
BRIDGEPORT CT
06604-2413
US

V. Phone/Fax

Practice location:
  • Phone: 203-853-2732
  • Fax: 203-612-9781
Mailing address:
  • Phone: 203-853-2732
  • Fax: 203-612-9781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. LUIS M BREA
Title or Position: OWNER
Credential: DDS
Phone: 203-853-2732