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General NPI Number Information
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NPI Number | 1083847172
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Entity Type | Organization
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Legal Business Name | CONNECTICUT DENTAL GRUOP, LLC
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Dates
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Enumeration Date | 08/24/2009
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Last Update Date | 08/24/2009
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Provider Practice Location Address
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Address Line | 4699 MAIN ST SUITE 203
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City | BRIDGEPORT
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State | CT
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Zip | 06606-1830
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Country | US
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Telephone | 203-372-4200
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Fax | 203-372-2376
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Provider Business Mailing Address
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Address Line | 4699 MAIN ST SUITE 203
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City | BRIDGEPORT
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State | CT
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Zip | 06606-1830
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Country | US
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Telephone | 203-372-4200
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Fax | 203-372-2376
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Authorized Official
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Title or Position | MEMBER
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Name | DR. MEHRAN AZAR
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Credential | D.D.S.
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Telephone | 203-372-4200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 08681
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License Number State | CT
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