Provider Demographics
NPI:1124316104
Name:DR DENTAL OF STRATFORD
Entity type:Organization
Organization Name:DR DENTAL OF STRATFORD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:
Authorized Official - Last Name:REVECHKIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-725-0372
Mailing Address - Street 1:200 E MAIN ST
Mailing Address - Street 2:UNIT 13
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-5114
Mailing Address - Country:US
Mailing Address - Phone:203-378-8500
Mailing Address - Fax:203-378-8501
Practice Address - Street 1:200 E MAIN ST
Practice Address - Street 2:UNIT 13
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-5114
Practice Address - Country:US
Practice Address - Phone:203-378-8500
Practice Address - Fax:203-378-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0100251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty