Healthcare Provider Details

I. General information

NPI: 1154745867
Provider Name (Legal Business Name): MILFORD DENTAL SPECIALIST, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2014
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 BOSTON POST RD SUITE 312
MILFORD CT
06460-3161
US

IV. Provider business mailing address

209 BOSTON POST RD SUITE 312
MILFORD CT
06460-3161
US

V. Phone/Fax

Practice location:
  • Phone: 203-876-9965
  • Fax: 203-876-9972
Mailing address:
  • Phone: 203-876-9965
  • Fax: 203-876-9972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number008668
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. JESUS A VILLEGAS
Title or Position: PEDIATRIC
Credential: D.D.S
Phone: 203-876-9965