Provider Demographics
NPI:1548626823
Name:TRUMBULL PREMIER DENTAL
Entity type:Organization
Organization Name:TRUMBULL PREMIER DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PABLO
Authorized Official - Middle Name:
Authorized Official - Last Name:CUEVAS
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-374-4300
Mailing Address - Street 1:4161 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-3533
Mailing Address - Country:US
Mailing Address - Phone:203-374-4300
Mailing Address - Fax:203-374-0479
Practice Address - Street 1:4161 MADISON AVE
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-3533
Practice Address - Country:US
Practice Address - Phone:203-374-4300
Practice Address - Fax:203-374-0479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-03
Last Update Date:2016-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7516122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty