Provider Demographics
NPI:1083173538
Name:RIDGEFIELD ORAL AND MAXILLOFACIAL SURGERY, LLC
Entity Type:Organization
Organization Name:RIDGEFIELD ORAL AND MAXILLOFACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:SMULLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:203-403-3686
Mailing Address - Street 1:87 BROOKHOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-1014
Mailing Address - Country:US
Mailing Address - Phone:617-230-1152
Mailing Address - Fax:
Practice Address - Street 1:10 SOUTH ST STE 202
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877-4125
Practice Address - Country:US
Practice Address - Phone:203-403-3686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty