Provider Demographics
NPI:1871221606
Name:FOUR CORNERS DENTAL STUDIO
Entity type:Organization
Organization Name:FOUR CORNERS DENTAL STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADI
Authorized Official - Middle Name:
Authorized Official - Last Name:KEDEM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-546-7351
Mailing Address - Street 1:802 FEDERAL RD STE 2
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-4008
Mailing Address - Country:US
Mailing Address - Phone:203-546-7351
Mailing Address - Fax:
Practice Address - Street 1:802 FEDERAL RD STE 2
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-4008
Practice Address - Country:US
Practice Address - Phone:203-546-7351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental