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General NPI Number Information
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NPI Number | 1366872137
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Entity Type | Organization
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Legal Business Name | FAMILY DENTISTRY OF STAMFORD PC
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Dates
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Enumeration Date | 11/15/2013
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Last Update Date | 11/15/2013
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Provider Practice Location Address
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Address Line | 1 STRAWBERRY HILL CT STE L6
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City | STAMFORD
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State | CT
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Zip | 06902-2548
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Country | US
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Telephone | 203-883-8330
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Fax |
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Provider Business Mailing Address
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Address Line | 1 STRAWBERRY HILL CT STE L6
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City | STAMFORD
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State | CT
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Zip | 06902-2548
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Country | US
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Telephone | 203-883-8330
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARK AGABABAEV
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Credential | DDS
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Telephone | 718-887-1397
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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 | 010091
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License Number State | CT
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