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General NPI Number Information
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NPI Number | 1629225875
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTAL ASSOCIATES OF SOUTHBURY LLC
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Dates
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Enumeration Date | 08/19/2008
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Last Update Date | 08/19/2008
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Provider Practice Location Address
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Address Line | 1 POMPERAUG OFFICE PARK SUITE 206
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City | SOUTHBURY
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State | CT
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Zip | 06488-2295
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Country | US
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Telephone | 203-264-1497
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Fax | 203-264-4039
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Provider Business Mailing Address
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Address Line | 1 POMPERAUG OFFICE PARK SUITE 206
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City | SOUTHBURY
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State | CT
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Zip | 06488-2295
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Country | US
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Telephone | 203-264-1497
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Fax | 203-264-4039
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MS. MARGUERITE C GILLETTE
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Credential |
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Telephone | 203-264-1497
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 007834
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License Number State | CT
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