Provider Demographics
NPI:1588048748
Name:CT BRACES BRIDGEPORT ORTHODONTICS PC
Entity type:Organization
Organization Name:CT BRACES BRIDGEPORT ORTHODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORTHODONTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SHYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-374-1911
Mailing Address - Street 1:3909 MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-2872
Mailing Address - Country:US
Mailing Address - Phone:203-374-1911
Mailing Address - Fax:203-683-0524
Practice Address - Street 1:3909 MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-2872
Practice Address - Country:US
Practice Address - Phone:203-374-1911
Practice Address - Fax:203-683-0524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0098021223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty