MEDICARE: PERLA DENTAL OF BRIDGEPORT PC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1730448978
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERLA DENTAL OF BRIDGEPORT PC

Provider Business Mailing Address
First Line	:	1801 LANTANA CT
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-3571
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4575 MAIN ST
Second Line	:	SUITE 125
City	:	BRIDGEPORT
State	:	CT
Zip	:	06606-1818
Country	:	US
Telephone Number	:	469-387-3332
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAYESHA HUSSAIN
Credential	:	DDS
Telephone Number	:	469-387-3332

Provider Enumeration Date	:	05/09/2012
Last Update Date	:	05/09/2012

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