Provider Demographics
NPI:1427756949
Name:DIVINE DENTISTRY PC
Entity type:Organization
Organization Name:DIVINE DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:ALEXIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-372-9848
Mailing Address - Street 1:2452 BLACK ROCK TPKE STE 12
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-2417
Mailing Address - Country:US
Mailing Address - Phone:203-372-9848
Mailing Address - Fax:
Practice Address - Street 1:2452 BLACK ROCK TPKE STE 12
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-2417
Practice Address - Country:US
Practice Address - Phone:203-372-9848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty