Healthcare Provider Details

I. General information

NPI: 1609016963
Provider Name (Legal Business Name): TOOTH FAIRY PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2009
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 COPPS HILL RD SUITE 6
RIDGEFIELD CT
06877-4041
US

IV. Provider business mailing address

35 COPPS HILL RD SUITE 6
RIDGEFIELD CT
06877-4041
US

V. Phone/Fax

Practice location:
  • Phone: 203-403-2525
  • Fax: 203-403-2545
Mailing address:
  • Phone: 203-403-2525
  • Fax: 203-403-2545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9135
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9091
License Number StateCT

VIII. Authorized Official

Name: DR. SUHO LEE
Title or Position: OWNER
Credential: DDS
Phone: 203-403-2525