Provider Demographics
NPI:1851958029
Name:PREMIER ORAL SURGERY AND IMPLANTOLOGY CENTER LLC
Entity Type:Organization
Organization Name:PREMIER ORAL SURGERY AND IMPLANTOLOGY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:BANGIYEV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:203-960-1960
Mailing Address - Street 1:324 ELM ST STE 201A
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-2282
Mailing Address - Country:US
Mailing Address - Phone:203-690-1960
Mailing Address - Fax:
Practice Address - Street 1:324 ELM ST STE 201A
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2282
Practice Address - Country:US
Practice Address - Phone:203-690-1960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER ORAL SURGERY AND IMPLANTOLOGY CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty