MEDICARE: ELMWOOD AND MAIN 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1972339927
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELMWOOD AND MAIN DENTISTRY LLC

Provider Business Mailing Address
First Line	:	105 MAIN ST STE A
Second Line	:
City	:	OLD SAYBROOK
State	:	CT
Zip	:	06475-2393
Country	:	US
Telephone Number	:	860-388-9774
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 MAIN ST UNIT 1
Second Line	:
City	:	OLD SAYBROOK
State	:	CT
Zip	:	06475-2393
Country	:	US
Telephone Number	:	321-591-4571
Fax Number	:

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	DR. DEREK CHENET
Credential	:	DDS
Telephone Number	:	321-591-4571

Provider Enumeration Date	:	09/09/2024
Last Update Date	:	04/07/2026

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