Healthcare Provider Details

I. General information

NPI: 1790133445
Provider Name (Legal Business Name): MASTERS DENTAL ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 06/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 NORTH AVE
NORWALK CT
06851-3827
US

IV. Provider business mailing address

37 NORTH AVE
NORWALK CT
06851-3827
US

V. Phone/Fax

Practice location:
  • Phone: 203-853-0880
  • Fax:
Mailing address:
  • Phone: 203-853-0880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateNULL

VIII. Authorized Official

Name: ALAN ROSENTHAL
Title or Position: OWNER
Credential: DMD
Phone: 203-853-0880