=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194815530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN C BRITZ DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 971 EAST BROADWAY
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-375-0884
-----------------------------------------------------
Fax | 203-378-0075
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 971 EAST BROADWAY
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-375-0884
-----------------------------------------------------
Fax | 203-378-0075
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT SECRETARY
-----------------------------------------------------
Name | JOHN C BRITZ
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 203-375-0884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 004724
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------