Provider Demographics
NPI:1184634313
Name:ORAL SURGERY ASSOCIATES, L.L.C
Entity Type:Organization
Organization Name:ORAL SURGERY ASSOCIATES, L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WHELAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-371-5595
Mailing Address - Street 1:4747 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606
Mailing Address - Country:US
Mailing Address - Phone:203-371-5595
Mailing Address - Fax:
Practice Address - Street 1:4747 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1804
Practice Address - Country:US
Practice Address - Phone:203-371-5595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT49821223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTT23109Medicare UPIN