Provider Demographics
NPI:1407455538
Name:GLASTONBURY IMPLANT DENTISTRY ORAL AND FACIAL SURGURY CENTER PC
Entity Type:Organization
Organization Name:GLASTONBURY IMPLANT DENTISTRY ORAL AND FACIAL SURGURY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:ANSARI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-649-7374
Mailing Address - Street 1:483 MIDDLE TPKE W STE 102
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-3864
Mailing Address - Country:US
Mailing Address - Phone:860-649-2272
Mailing Address - Fax:860-533-1010
Practice Address - Street 1:131 NEW LONDON TPKE
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2246
Practice Address - Country:US
Practice Address - Phone:860-649-7374
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty