Basic Information
| Provider Information | |||||||||
| NPI: | 1972907012 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPTIMUS HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 982 E MAIN ST | ||||||||
| Address2: | DENTAL DEPARTMENT | ||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066081913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036963260 | ||||||||
| FaxNumber: | 2033348104 | ||||||||
| Practice Location | |||||||||
| Address1: | 982 E MAIN ST | ||||||||
| Address2: | DENTAL DEPARTMENT | ||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066081913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036963260 | ||||||||
| FaxNumber: | 2033348104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2014 | ||||||||
| LastUpdateDate: | 10/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | KOTSAY | ||||||||
| AuthorizedOfficialFirstName: | KRIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DENTAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2036963260 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 006486 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 1669548376 | 05 | CT | MEDICAID |