MEDICARE: THE LITTLE TOOTH COMPANY PEDIATRIC DENTISTRY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	9915	CT

General Provider Information

NPI Number	:	1023569654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE LITTLE TOOTH COMPANY PEDIATRIC DENTISTRY LLC

Provider Business Mailing Address
First Line	:	264 QUEEN ST
Second Line	:	SUITE A
City	:	SOUTHINGTON
State	:	CT
Zip	:	06489-1901
Country	:	US
Telephone Number	:	617-872-5105
Fax Number	:

Provider Business Practice Location Address
First Line	:	264 QUEEN ST
Second Line	:	SUITE A
City	:	SOUTHINGTON
State	:	CT
Zip	:	06489-1901
Country	:	US
Telephone Number	:	617-872-5105
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JASON LEUNG
Credential	:	DMD
Telephone Number	:	860-426-2643

Provider Enumeration Date	:	10/19/2016
Last Update Date	:	10/19/2016

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