NPIMap

Organization Active NPI

Pediatric Dental Associates of Southbury LLC

  • Pediatric Dentistry
  • Southbury, CT
National Provider Identifier
1629225875
Registry record updated Aug 19, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric DentistryTaxonomy code 1223P0221X
License
007834 Issued in CT
Legal business name
PEDIATRIC DENTAL ASSOCIATES OF SOUTHBURY LLC
Practice address
1 Pomperaug Office Park
Suite 206
Southbury, CT 06488-2295
Phone
(203) 264-1497
Fax
(203) 264-4039
NPI assigned
Aug 19, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 19, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Marguerite C Gillette
Title
Office Manager
Phone
(203) 264-1497

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223P0221X 007834 CT Primary

Addresses

Primary practice location

1 Pomperaug Office Park
Suite 206
Southbury, CT 06488-2295

Mailing address

1 Pomperaug Office Park
Suite 206
Southbury, CT 06488-2295
Phone (203) 264-1497

Other identifiers 1

IdentifierTypeStateIssuer
008001055MedicaidCT

National Provider Directory

National Provider Directory

Locations

1 Pomperaug Office Park
Ste 206
Southbury, CT 06488
Phone (203) 264-1497

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1219104000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1219104000000",
    "number": "1629225875",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 POMPERAUG OFFICE PARK",
            "address_2": "SUITE 206",
            "city": "SOUTHBURY",
            "state": "CT",
            "postal_code": "064882295",
            "telephone_number": "203-264-1497",
            "fax_number": "203-264-4039"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 POMPERAUG OFFICE PARK",
            "address_2": "SUITE 206",
            "city": "SOUTHBURY",
            "state": "CT",
            "postal_code": "064882295",
            "telephone_number": "203-264-1497",
            "fax_number": "203-264-4039"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEDIATRIC DENTAL ASSOCIATES OF SOUTHBURY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-08-19",
        "last_updated": "2008-08-19",
        "status": "A",
        "authorized_official_last_name": "GILLETTE",
        "authorized_official_first_name": "MARGUERITE",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "203-264-1497",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "CT",
            "license": "007834",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "008001055",
            "state": "CT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Southbury, CT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 19, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.