Healthcare Provider Details

I. General information

NPI: 1609311604
Provider Name (Legal Business Name): EAST HAMPTON FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2016
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 W HIGH ST
EAST HAMPTON CT
06424-1024
US

IV. Provider business mailing address

41 W HIGH ST
EAST HAMPTON CT
06424-1024
US

V. Phone/Fax

Practice location:
  • Phone: 860-267-9904
  • Fax: 860-267-7270
Mailing address:
  • Phone: 860-267-9904
  • Fax: 860-267-7270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11346
License Number StateCT

VIII. Authorized Official

Name: VIJAYALAKSHMI CANAKALAVENKATA
Title or Position: OWNER
Credential: DMD
Phone: 860-267-9904