Provider Demographics
NPI:1669795381
Name:IMPERIAL DENTAL ASSOC., PC
Entity type:Organization
Organization Name:IMPERIAL DENTAL ASSOC., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GENI-BLANEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-227-2520
Mailing Address - Street 1:15 IMPERIAL AVE
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-4302
Mailing Address - Country:US
Mailing Address - Phone:203-227-2520
Mailing Address - Fax:203-454-8710
Practice Address - Street 1:15 IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4302
Practice Address - Country:US
Practice Address - Phone:203-227-2520
Practice Address - Fax:203-454-8710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0084291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty