Healthcare Provider Details

I. General information

NPI: 1588048748
Provider Name (Legal Business Name): CT BRACES BRIDGEPORT ORTHODONTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 MAIN ST SUITE A
BRIDGEPORT CT
06606-2872
US

IV. Provider business mailing address

3909 MAIN ST SUITE A
BRIDGEPORT CT
06606-2872
US

V. Phone/Fax

Practice location:
  • Phone: 203-374-1911
  • Fax: 203-683-0524
Mailing address:
  • Phone: 203-374-1911
  • Fax: 203-683-0524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number009802
License Number StateCT

VIII. Authorized Official

Name: MR. SHYAM DESAI
Title or Position: OWNER/ORTHODONTIST
Credential: D.M.D
Phone: 203-374-1911