Provider Demographics
NPI:1881930501
Name:FAMILY DENTISTRY OF DERBY P.C
Entity type:Organization
Organization Name:FAMILY DENTISTRY OF DERBY P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:AGABABAEV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-887-1397
Mailing Address - Street 1:115 NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-2154
Mailing Address - Country:US
Mailing Address - Phone:203-751-9657
Mailing Address - Fax:203-751-9827
Practice Address - Street 1:115 NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-2154
Practice Address - Country:US
Practice Address - Phone:203-751-9657
Practice Address - Fax:203-751-9827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-27
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty