=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518091412
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL ASSOCIATES OF SOUTHERN NEW ENGLAND, P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 98 ELM ST
-----------------------------------------------------
City | WEST HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06516-3879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-933-6974
-----------------------------------------------------
Fax | 203-931-9580
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 98 ELM ST
-----------------------------------------------------
City | WEST HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06516-3879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-933-6974
-----------------------------------------------------
Fax | 203-931-9580
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RICHARD J. PANAGROSSI JR.
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 203-933-6974
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------