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General NPI Number Information
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NPI Number | 1790078418
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Entity Type | Organization
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Legal Business Name | A&G FAMILY DENTISTRY PC
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Dates
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Enumeration Date | 05/27/2011
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Last Update Date | 05/27/2011
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Provider Practice Location Address
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Address Line | 1127 W MAIN ST STE 2A
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City | WATERBURY
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State | CT
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Zip | 06708-2764
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Country | US
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Telephone | 203-573-9989
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Fax |
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Provider Business Mailing Address
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Address Line | 2354 OCEAN PKWY
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City | BROOKLYN
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State | NY
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Zip | 11223-5447
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Country | US
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Telephone | 718-887-1397
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | DR. MARK AGABABAEV
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Credential | DDS
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Telephone | 718-887-1397
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 010091
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License Number State | CT
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