Provider Demographics
NPI:1053705061
Name:NORTH END DENTAL ASSOCIATES, PC
Entity type:Organization
Organization Name:NORTH END DENTAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMUTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAGURAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:650-576-8237
Mailing Address - Street 1:4699 MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1830
Mailing Address - Country:US
Mailing Address - Phone:203-372-4296
Mailing Address - Fax:203-372-4734
Practice Address - Street 1:4699 MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1830
Practice Address - Country:US
Practice Address - Phone:203-372-4296
Practice Address - Fax:203-372-4734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty