Healthcare Provider Details

I. General information

NPI: 1821503210
Provider Name (Legal Business Name): MGM FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2017
Last Update Date: 12/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2690 E MAIN ST
BRIDGEPORT CT
06610-1422
US

IV. Provider business mailing address

2690 E MAIN ST
BRIDGEPORT CT
06610-1422
US

V. Phone/Fax

Practice location:
  • Phone: 203-612-6079
  • Fax: 203-612-6081
Mailing address:
  • Phone: 203-612-6079
  • Fax: 203-612-6081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number11154
License Number StateCT

VIII. Authorized Official

Name: DR. HAMED GHORBANI-MOGHADDAM
Title or Position: OWNER
Credential: DDS
Phone: 203-612-6079