Provider Demographics
NPI:1861779373
Name:JSAM, LLC
Entity type:Organization
Organization Name:JSAM, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHALAK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-488-6553
Mailing Address - Street 1:420 E MAIN ST
Mailing Address - Street 2:BUILDING 3, SUITE #17
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-2940
Mailing Address - Country:US
Mailing Address - Phone:203-488-6553
Mailing Address - Fax:
Practice Address - Street 1:420 E MAIN ST
Practice Address - Street 2:BUILDING 3, SUITE #17
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-2940
Practice Address - Country:US
Practice Address - Phone:203-488-6553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-11
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009451122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty