Provider Demographics
NPI:1811199458
Name:COASTAL CONNECTICUT ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:COASTAL CONNECTICUT ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:HAMDEN SHORELINE ORAL AND MAXILLOFACIAL SURGERY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:SALOMON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-458-4450
Mailing Address - Street 1:246 GOOSE LN STE 204
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2186
Mailing Address - Country:US
Mailing Address - Phone:203-453-7700
Mailing Address - Fax:203-458-2708
Practice Address - Street 1:246 GOOSE LN STE 204
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2186
Practice Address - Country:US
Practice Address - Phone:203-453-7700
Practice Address - Fax:203-458-5085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC01303Medicare PIN