Provider Demographics
NPI:1871714147
Name:KEITH H. WADE DMD PC
Entity type:Organization
Organization Name:KEITH H. WADE DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOK KEEPER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-266-7435
Mailing Address - Street 1:101 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:CT
Mailing Address - Zip Code:06751-2032
Mailing Address - Country:US
Mailing Address - Phone:203-266-7435
Mailing Address - Fax:203-266-5100
Practice Address - Street 1:101 MAIN ST S
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:CT
Practice Address - Zip Code:06751-2032
Practice Address - Country:US
Practice Address - Phone:203-266-7435
Practice Address - Fax:203-266-5100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0073501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty