Provider Demographics
NPI:1528162633
Name:EAST HADDAM DENTAL ASSOCIATES PC
Entity type:Organization
Organization Name:EAST HADDAM DENTAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KARL
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:STOFKO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-873-1404
Mailing Address - Street 1:PO BOX 362
Mailing Address - Street 2:
Mailing Address - City:MOODUS
Mailing Address - State:CT
Mailing Address - Zip Code:06469-0362
Mailing Address - Country:US
Mailing Address - Phone:860-873-1404
Mailing Address - Fax:860-873-1405
Practice Address - Street 1:32 WILLIAM F PALMER ROAD
Practice Address - Street 2:
Practice Address - City:MOODUS
Practice Address - State:CT
Practice Address - Zip Code:06469
Practice Address - Country:US
Practice Address - Phone:860-873-1404
Practice Address - Fax:860-873-1405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty