=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275934051
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESTERN CONNECTICUT DENTAL ARTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2014
-----------------------------------------------------
Last Update Date | 09/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 PARK LANE RD UNIT B201
-----------------------------------------------------
City | NEW MILFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06776-2444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-350-9232
-----------------------------------------------------
Fax | 860-355-9232
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 PARK LANE RD UNIT B201
-----------------------------------------------------
City | NEW MILFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06776-2444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-350-9232
-----------------------------------------------------
Fax | 860-355-9232
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KEVIN M STANTON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 860-350-9232
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 006219
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 009825
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------