Provider Demographics
NPI:1689182842
Name:MYOLOGY OROFACIAL THERAPY LLC
Entity Type:Organization
Organization Name:MYOLOGY OROFACIAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED OROFACIAL MYOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:QUARANTA
Authorized Official - Suffix:
Authorized Official - Credentials:RDH, MS, COM
Authorized Official - Phone:203-451-3780
Mailing Address - Street 1:250 THUNDER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-1339
Mailing Address - Country:US
Mailing Address - Phone:203-451-3780
Mailing Address - Fax:
Practice Address - Street 1:44 OLD RIDGEFIELD RD
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-3055
Practice Address - Country:US
Practice Address - Phone:203-451-3780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005750124Q00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty