Healthcare Provider Details

I. General information

NPI: 1811145857
Provider Name (Legal Business Name): FAIRFIELD PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 06/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 BOSTON POST RD SUITE 201
MILFORD CT
06460-3161
US

IV. Provider business mailing address

209 BOSTON POST RD SUITE 201
MILFORD CT
06460-3161
US

V. Phone/Fax

Practice location:
  • Phone: 203-783-9994
  • Fax: 203-783-9961
Mailing address:
  • Phone: 203-783-9994
  • Fax: 203-783-9961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JESUS A VILLEGAS
Title or Position: MEMBER/DENTIST
Credential:
Phone: 203-783-9994