Provider Demographics
NPI:1730448978
Name:PERLA DENTAL OF BRIDGEPORT PC
Entity type:Organization
Organization Name:PERLA DENTAL OF BRIDGEPORT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAYESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUSSAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:469-387-3332
Mailing Address - Street 1:1801 LANTANA CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-3571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4575 MAIN ST
Practice Address - Street 2:SUITE 125
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1818
Practice Address - Country:US
Practice Address - Phone:469-387-3332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty