Provider Demographics
NPI:1447548805
Name:STAMFORD PEDIATRIC DENTISTRY, LLC
Entity type:Organization
Organization Name:STAMFORD PEDIATRIC DENTISTRY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAE
Authorized Official - Middle Name:CHUL
Authorized Official - Last Name:HO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-342-4141
Mailing Address - Street 1:4 LONG RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-3802
Mailing Address - Country:US
Mailing Address - Phone:860-342-4141
Mailing Address - Fax:860-342-1284
Practice Address - Street 1:4 LONG RIDGE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-3802
Practice Address - Country:US
Practice Address - Phone:860-342-4141
Practice Address - Fax:860-342-1284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT98461223P0221X
CT99201223P0221X
CT009846261QD0000X, 261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial SurgeryGroup - Multi-Specialty