Provider Demographics
NPI:1558382572
Name:CONNECTICUT VALLEY ORAL SURGERY ASSOCIATES, PC
Entity Type:Organization
Organization Name:CONNECTICUT VALLEY ORAL SURGERY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:EBBIGHAUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-357-3709
Mailing Address - Street 1:243 KING ST
Mailing Address - Street 2:STE 101
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060
Mailing Address - Country:US
Mailing Address - Phone:413-585-0002
Mailing Address - Fax:413-584-9583
Practice Address - Street 1:243 KING ST
Practice Address - Street 2:SUITE 101
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-2451
Practice Address - Country:US
Practice Address - Phone:413-585-0002
Practice Address - Fax:413-584-9583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
X11144Medicare ID - Type Unspecified