=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750696399
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONNECTICUT FAMILY DENTAL, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2010
-----------------------------------------------------
Last Update Date | 05/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3885 MAIN ST SUITE 101
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06606-2814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-663-2772
-----------------------------------------------------
Fax | 203-275-8595
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3885 MAIN ST SUITE 101
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06606-2814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-663-2772
-----------------------------------------------------
Fax | 203-275-8595
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE-PRESIDENT
-----------------------------------------------------
Name | MR. JACKSON MENDES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-663-2772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 10567
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 008314
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------