Provider Demographics
NPI:1417155276
Name:FACIAL COSMETIC & MAXILLOFACIAL SURGERY P.C.
Entity Type:Organization
Organization Name:FACIAL COSMETIC & MAXILLOFACIAL SURGERY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:FRAZIERO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD FADSA
Authorized Official - Phone:413-525-0100
Mailing Address - Street 1:382 N MAIN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:EAST LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01028-1828
Mailing Address - Country:US
Mailing Address - Phone:413-525-0100
Mailing Address - Fax:413-525-8608
Practice Address - Street 1:382 N MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-1828
Practice Address - Country:US
Practice Address - Phone:413-525-0100
Practice Address - Fax:413-525-8608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0166841223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0272167Medicaid
MAT91325Medicare UPIN
MAX06153Medicare ID - Type Unspecified