Provider Demographics
NPI:1912035213
Name:ORAL & MAXILLOFACIAL SURGEONS OF MILFORD & DERBY, PC
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGEONS OF MILFORD & DERBY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:D
Authorized Official - Last Name:FABIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-874-1664
Mailing Address - Street 1:1 GOLDEN HILL ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-4630
Mailing Address - Country:US
Mailing Address - Phone:203-874-1664
Mailing Address - Fax:203-877-2027
Practice Address - Street 1:1 GOLDEN HILL ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-4630
Practice Address - Country:US
Practice Address - Phone:203-874-1664
Practice Address - Fax:203-877-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT020004683CT02OtherANTHEM BLUE CROSS
CT020006602CT01OtherANTHEM BLUE CROSS
CT190000611Medicare ID - Type Unspecified
CTT22002Medicare UPIN
CT020006602CT01OtherANTHEM BLUE CROSS
CT190000455Medicare ID - Type Unspecified