Provider Demographics
NPI:1073633426
Name:GREENWICH ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:GREENWICH ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRODY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-661-5858
Mailing Address - Street 1:23 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-5620
Mailing Address - Country:US
Mailing Address - Phone:203-661-5858
Mailing Address - Fax:203-661-1159
Practice Address - Street 1:23 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-5620
Practice Address - Country:US
Practice Address - Phone:203-661-5858
Practice Address - Fax:203-661-1159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049719-11223S0112X
CT0095521223S0112X
CT70231223S0112X
NY0407601223S0112X
CT62371223S0112X
NY0331811223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1518057389OtherNPI
NPIOther1255421012
CT1649298944OtherNPI
NYD67912Medicare ID - Type Unspecified
NYD2E941Medicare UPIN
CT1649298944OtherNPI
CTT22414Medicare UPIN