MEDICARE: ELM FAMILY DENTAL ASSOCIATES 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	009760	CT
2	1223G0001X	General Practice Dentistry	008755	CT

General Provider Information

NPI Number	:	1679746093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELM FAMILY DENTAL ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	233 ELM ST
Second Line	:
City	:	WEST HAVEN
State	:	CT
Zip	:	06516-4635
Country	:	US
Telephone Number	:	203-933-2223
Fax Number	:	203-933-2220

Provider Business Practice Location Address
First Line	:	233 ELM ST
Second Line	:
City	:	WEST HAVEN
State	:	CT
Zip	:	06516-4635
Country	:	US
Telephone Number	:	203-933-2223
Fax Number	:	203-933-2220

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL A NORMAN
Credential	:	D.M.D
Telephone Number	:	203-933-2223

Provider Enumeration Date	:	04/07/2008
Last Update Date	:	05/09/2013

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