Healthcare Provider Details

I. General information

NPI: 1619171790
Provider Name (Legal Business Name): KIDS DENTAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 07/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 TERRYVILLE AVE
BRISTOL CT
06010-4034
US

IV. Provider business mailing address

733 TERRYVILLE AVE
BRISTOL CT
06010-4034
US

V. Phone/Fax

Practice location:
  • Phone: 860-584-0441
  • Fax: 860-516-8918
Mailing address:
  • Phone: 860-584-0441
  • Fax: 860-516-8918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number6903
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10813
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number008462
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number10740
License Number StateCT
# 5
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7893
License Number StateCT

VIII. Authorized Official

Name: DR. AMMAR IDLIBI
Title or Position: OWNER
Credential:
Phone: 860-584-0441