Healthcare Provider Details

I. General information

NPI: 1679746093
Provider Name (Legal Business Name): ELM FAMILY DENTAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 ELM ST
WEST HAVEN CT
06516-4635
US

IV. Provider business mailing address

233 ELM ST
WEST HAVEN CT
06516-4635
US

V. Phone/Fax

Practice location:
  • Phone: 203-933-2223
  • Fax: 203-933-2220
Mailing address:
  • Phone: 203-933-2223
  • Fax: 203-933-2220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number008755
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number009760
License Number StateCT

VIII. Authorized Official

Name: MICHAEL A NORMAN
Title or Position: OWNER
Credential: D.M.D
Phone: 203-933-2223