Provider Demographics
NPI:1104183409
Name:CENTRAL CTONNECTICUT ORAL MAXILLOFACIAL& IMPLANT SURGERY, PC
Entity Type:Organization
Organization Name:CENTRAL CTONNECTICUT ORAL MAXILLOFACIAL& IMPLANT SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:860-586-8507
Mailing Address - Street 1:836 FARMINGTON AVE
Mailing Address - Street 2:SUITE 223
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1505
Mailing Address - Country:US
Mailing Address - Phone:860-586-8507
Mailing Address - Fax:860-586-8697
Practice Address - Street 1:836 FARMINGTON AVE
Practice Address - Street 2:SUITE 223
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1505
Practice Address - Country:US
Practice Address - Phone:860-586-8507
Practice Address - Fax:860-586-8697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008001740Medicaid