Provider Demographics
NPI:1083818710
Name:CONNECTICUT ORAL & MAXILLOFACIAL SURGERY CENTERS, LLC
Entity Type:Organization
Organization Name:CONNECTICUT ORAL & MAXILLOFACIAL SURGERY CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BERKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-937-7181
Mailing Address - Street 1:323 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4424
Mailing Address - Country:US
Mailing Address - Phone:203-937-7181
Mailing Address - Fax:203-937-1940
Practice Address - Street 1:323 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4424
Practice Address - Country:US
Practice Address - Phone:203-937-7181
Practice Address - Fax:203-937-1940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT70261223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty