Basic Information
| Provider Information | |||||||||
| NPI: | 1619940962 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEVINSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 471 BARNUM AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066082409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033336864 | ||||||||
| FaxNumber: | 2033320376 | ||||||||
| Practice Location | |||||||||
| Address1: | 982 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066081913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036963270 | ||||||||
| FaxNumber: | 2033348104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 08/20/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 005321 | CT | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 002053213 | 05 | CT | MEDICAID |