=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588955538
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERFECT SMILES OF FAIRFIELD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2011
-----------------------------------------------------
Last Update Date | 04/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 KATONA DR SUITE 20
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06824-3544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-561-5749
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 60 KATONA DRIVE SUITE 20
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-561-5749
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. CAROLINE SHENKER
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 203-561-5749
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 009131
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------