=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922122332
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIMSBURY PEDIATRIC & ADOLESCENT DENTISTRY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 381 HOPMEADOW ST SUITE 202
-----------------------------------------------------
City | WEATOGUE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06089-9692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-658-7548
-----------------------------------------------------
Fax | 860-658-7516
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 381 HOPMEADOW ST SUITE 202
-----------------------------------------------------
City | WEATOGUE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06089-9692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-658-7548
-----------------------------------------------------
Fax | 860-658-7516
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST, OWNER
-----------------------------------------------------
Name | DR. MARYAM AZADPUR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 860-658-7548
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 007907
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------