Healthcare Provider Details

I. General information

NPI: 1487656377
Provider Name (Legal Business Name): DAVID R EDELSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/22/2006
Reactivation Date: 05/03/2006

III. Provider practice location address

92 EAST ST
PLAINVILLE CT
06062-2302
US

IV. Provider business mailing address

92 EAST ST
PLAINVILLE CT
06062-2302
US

V. Phone/Fax

Practice location:
  • Phone: 860-747-1004
  • Fax: 860-793-2219
Mailing address:
  • Phone: 860-747-1004
  • Fax: 860-793-2219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number006399
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: