Provider Demographics
NPI:1053782060
Name:CONNECTICUT CENTER FOR ORAL FACIAL AND IMPLANT SURGERY PC
Entity type:Organization
Organization Name:CONNECTICUT CENTER FOR ORAL FACIAL AND IMPLANT SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:MARSHALL
Authorized Official - Last Name:GADY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:860-231-1030
Mailing Address - Street 1:80 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2408
Mailing Address - Country:US
Mailing Address - Phone:860-231-1030
Mailing Address - Fax:860-231-1032
Practice Address - Street 1:80 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2408
Practice Address - Country:US
Practice Address - Phone:860-231-1030
Practice Address - Fax:860-231-1032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-16
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT011331261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery