=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548626823
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRUMBULL PREMIER DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2016
-----------------------------------------------------
Last Update Date | 01/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4161 MADISON AVE
-----------------------------------------------------
City | TRUMBULL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06611-3533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-374-4300
-----------------------------------------------------
Fax | 203-374-0479
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4161 MADISON AVE
-----------------------------------------------------
City | TRUMBULL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06611-3533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-374-4300
-----------------------------------------------------
Fax | 203-374-0479
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | DR. PABLO CUEVAS III
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 203-374-4300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 7516
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------