Provider Demographics
NPI:1396866927
Name:FEDORCIW AND MASSOUMI LLC
Entity Type:Organization
Organization Name:FEDORCIW AND MASSOUMI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEHRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSOUMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-635-4666
Mailing Address - Street 1:26 SHUNPIKE RD
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-2442
Mailing Address - Country:US
Mailing Address - Phone:860-635-4666
Mailing Address - Fax:860-635-3621
Practice Address - Street 1:26 SHUNPIKE RD
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-2442
Practice Address - Country:US
Practice Address - Phone:860-635-4666
Practice Address - Fax:860-635-3621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8806261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental