Provider Demographics
NPI:1053704445
Name:PEDIATRIC DENTAL SEDATION SPECIALIST OF CONNECTICUT LLC
Entity type:Organization
Organization Name:PEDIATRIC DENTAL SEDATION SPECIALIST OF CONNECTICUT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LEVY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-841-7780
Mailing Address - Street 1:17A SINTSINK DR W
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-2015
Mailing Address - Country:US
Mailing Address - Phone:248-217-4590
Mailing Address - Fax:
Practice Address - Street 1:120 EAST AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-5703
Practice Address - Country:US
Practice Address - Phone:203-817-2534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-10
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0104951223D0004X
CT0059451223E0200X
CT0104731223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDental AnesthesiologyGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty