Healthcare Provider Details

I. General information

NPI: 1568013001
Provider Name (Legal Business Name): CPDENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2019
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 JOHN ST
SOUTHPORT CT
06890-1437
US

IV. Provider business mailing address

10 JOHN ST
SOUTHPORT CT
06890-1437
US

V. Phone/Fax

Practice location:
  • Phone: 203-255-5142
  • Fax: 203-259-5954
Mailing address:
  • Phone: 203-255-5142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. PAMELA GIBSON
Title or Position: MEMBER
Credential: DMD
Phone: 203-435-1751