=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295028942
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST MAIN DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2011
-----------------------------------------------------
Last Update Date | 05/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 87 W MAIN ST UNIT 105A
-----------------------------------------------------
City | NEW BRITAIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06051-2216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-939-1460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 87 W MAIN ST UNIT 105A
-----------------------------------------------------
City | NEW BRITAIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06051-2216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-939-1460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. KHURRAM ASGHER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 203-939-1460
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 10342
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------