Provider Demographics
NPI:1699185264
Name:CREST FAMILY DENTAL, LLC
Entity type:Organization
Organization Name:CREST FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIVAREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-514-1217
Mailing Address - Street 1:85 SEYMOUR ST
Mailing Address - Street 2:SUITE 1018
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-5501
Mailing Address - Country:US
Mailing Address - Phone:860-251-6999
Mailing Address - Fax:860-251-6997
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 1018
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-251-6999
Practice Address - Fax:860-251-6997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT106901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1223G0001XMedicaid