MEDICARE: PEDIATRIC DENTISTRY 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	5525	CT
2	1223P0221X	Pediatric Dentistry	7814	CT
3	1223P0221X	Pediatric Dentistry	9409	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1710988704	OTHER	CT	INDIVIDUAL NPI
2	1760569685	OTHER	CT	INDIVIDUAL NPI
3	1184624058	OTHER	CT	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1982759791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC DENTISTRY ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	149 DURHAM RD STE 33
Second Line	:
City	:	MADISON
State	:	CT
Zip	:	06443-2680
Country	:	US
Telephone Number	:	203-245-1454
Fax Number	:	203-245-8998

Provider Business Practice Location Address
First Line	:	149 DURHAM RD STE 33
Second Line	:
City	:	MADISON
State	:	CT
Zip	:	06443-2680
Country	:	US
Telephone Number	:	203-245-1454
Fax Number	:	203-245-8998

Authorized Official
Title or Position	:	OWNER
Name	:	DOUGLAS B. KECK
Credential	:	D.M.D.
Telephone Number	:	203-787-3669

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	08/22/2020

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Directions to “PEDIATRIC DENTISTRY ASSOCIATES, LLC ” Practice Location

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