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General NPI Number Information
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NPI Number | 1053704445
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTAL SEDATION SPECIALIST OF CONNECTICUT LLC
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Dates
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Enumeration Date | 03/10/2015
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Last Update Date | 08/17/2015
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Provider Practice Location Address
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Address Line | 120 EAST AVE
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City | NORWALK
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State | CT
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Zip | 06851-5703
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Country | US
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Telephone | 203-817-2534
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Fax |
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Provider Business Mailing Address
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Address Line | 17A SINTSINK DR W
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City | PORT WASHINGTON
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State | NY
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Zip | 11050-2015
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Country | US
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Telephone | 248-217-4590
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. JESSICA LYNN LEVY
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Credential | DDS
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Telephone | 917-841-7780
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 010473
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 005945
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License Number State | CT
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Taxonomy #3
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Taxonomy Code | 1223D0004X
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Taxonomy Name | Dental Anesthesiology
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License Number | 010495
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License Number State | CT
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