Healthcare Provider Details

I. General information

NPI: 1316489990
Provider Name (Legal Business Name): JMJ DDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1823 BOSTON POST RD
WESTBROOK CT
06498-2048
US

IV. Provider business mailing address

1823 BOSTON POST RD
WESTBROOK CT
06498-2048
US

V. Phone/Fax

Practice location:
  • Phone: 860-399-7971
  • Fax:
Mailing address:
  • Phone: 860-399-7971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number006800
License Number StateCT

VIII. Authorized Official

Name: MR. JOHN M JOHNSON
Title or Position: OWNER
Credential: DDS
Phone: 860-399-7971