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General NPI Number Information
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NPI Number | 1093034621
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Entity Type | Organization
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Legal Business Name | NORTHEAST DENTAL SOLUTIONS LLC
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Dates
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Enumeration Date | 05/21/2010
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Last Update Date | 05/21/2010
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Provider Practice Location Address
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Address Line | 56 HARRIET ST FIRST FLOOR
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City | BRIDGEPORT
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State | CT
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Zip | 06608-2131
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Country | US
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Telephone | 203-338-0090
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Fax |
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Provider Business Mailing Address
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Address Line | 56 HARRIET ST FIRST FLOOR
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City | BRIDGEPORT
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State | CT
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Zip | 06608-2131
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Country | US
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Telephone | 203-338-0090
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Fax |
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Authorized Official
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Title or Position | PART OWNER/MANAGER
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Name | MR. CLIVE B. RUSELL
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Credential |
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Telephone | 203-338-0090
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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 | 009777
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 006295
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License Number State | CT
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