Basic Information
| Provider Information | |||||||||
| NPI: | 1104172881 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIDS DENTAL CARE ANESTHESIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 41 | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473080041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652840493 | ||||||||
| FaxNumber: | 7652842434 | ||||||||
| Practice Location | |||||||||
| Address1: | 733 TERRYVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060104034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605840441 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2012 | ||||||||
| LastUpdateDate: | 07/31/2012 | ||||||||
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| AuthorizedOfficialLastName: | AKBAR | ||||||||
| AuthorizedOfficialFirstName: | SALEH | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8605840441 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 039079 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.