Healthcare Provider Details

I. General information

NPI: 1053704445
Provider Name (Legal Business Name): PEDIATRIC DENTAL SEDATION SPECIALIST OF CONNECTICUT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2015
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 EAST AVE
NORWALK CT
06851-5703
US

IV. Provider business mailing address

17A SINTSINK DR W
PORT WASHINGTON NY
11050-2015
US

V. Phone/Fax

Practice location:
  • Phone: 203-817-2534
  • Fax:
Mailing address:
  • Phone: 248-217-4590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number010495
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number005945
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number010473
License Number StateCT

VIII. Authorized Official

Name: DR. JESSICA LYNN LEVY
Title or Position: MEMBER
Credential: DDS
Phone: 917-841-7780