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General NPI Number Information
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NPI Number | 1992160055
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Entity Type | Organization
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Legal Business Name | CONNECTICUT DENTAL ARTS
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Dates
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Enumeration Date | 12/16/2015
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Last Update Date | 12/16/2015
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Provider Practice Location Address
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Address Line | 100 STATE ROUTE 37
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City | NEW FAIRFIELD
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State | CT
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Zip | 06812-4024
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Country | US
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Telephone | 203-746-2459
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Fax | 203-746-2450
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Provider Business Mailing Address
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Address Line | 100 STATE ROUTE 37
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City | NEW FAIRFIELD
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State | CT
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Zip | 06812-4024
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Country | US
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Telephone | 203-746-2459
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Fax | 203-746-2450
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Authorized Official
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Title or Position | GENERAL DENTIST
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Name | DR. ROBERT JACOBS
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Credential | D.D.S., P.C.
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Telephone | 203-746-2459
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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 | 005149
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License Number State | CT
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