1972014744 NPI number — SHELTON DENTAL GROUP LLC

Table of content: (NPI 1972014744)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972014744 NPI number — SHELTON DENTAL GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHELTON DENTAL GROUP LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHELTON DENTAL GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972014744
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
169 CENTER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06484-3241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-925-9425
Provider Business Mailing Address Fax Number:
203-922-9322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
169 CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06484-3241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-925-9425
Provider Business Practice Location Address Fax Number:
203-922-9322
Provider Enumeration Date:
10/19/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SINGH
Authorized Official First Name:
YADVERINDER
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER OF LLC
Authorized Official Telephone Number:
860-595-8388

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  11046 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)