Provider Demographics
NPI:1801013727
Name:AVON ORAL AND MAXILLOFACIAL SURGERY, LLP
Entity Type:Organization
Organization Name:AVON ORAL AND MAXILLOFACIAL SURGERY, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:HINMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-674-8079
Mailing Address - Street 1:34 DALE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3659
Mailing Address - Country:US
Mailing Address - Phone:860-674-8079
Mailing Address - Fax:860-676-8242
Practice Address - Street 1:34 DALE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3659
Practice Address - Country:US
Practice Address - Phone:860-674-8079
Practice Address - Fax:860-676-8242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0087321223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002087329Medicaid
CT002064939Medicaid
CT001388207Medicaid
CT004397718Medicaid
CT004206977Medicaid
CTU82746Medicare UPIN
CT004397718Medicaid
CT190000659Medicare ID - Type UnspecifiedFOR S. E. LIEBLICH
CTC52341Medicare UPIN
CTC01208Medicare ID - Type UnspecifiedFOR GROUP
CT002087329Medicaid