Healthcare Provider Details

I. General information

NPI: 1184057192
Provider Name (Legal Business Name): HAMDEN FAMILY DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4193 WHITNEY AVE
HAMDEN CT
06518-1212
US

IV. Provider business mailing address

4193 WHITNEY AVE
HAMDEN CT
06518-1212
US

V. Phone/Fax

Practice location:
  • Phone: 203-248-4080
  • Fax: 203-248-4743
Mailing address:
  • Phone: 203-248-4080
  • Fax: 203-248-4743

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: TAM H LE
Title or Position: MEMBER
Credential: DMD
Phone: 203-248-4080