Healthcare Provider Details

I. General information

NPI: 1275806481
Provider Name (Legal Business Name): IRVING M EDELSON DDS AND DAVID R EDELSON DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2012
Last Update Date: 06/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

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 TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number006399
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. DAVID ROSS EDELSON
Title or Position: PRESIDENT
Credential: DMD
Phone: 860-747-1004