Provider Demographics
NPI:1205906369
Name:EAST LYME ORAL AND MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:EAST LYME ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER AND OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:FRED
Authorized Official - Last Name:ENGEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-739-3133
Mailing Address - Street 1:314 FLANDERS RD
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:EAST LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06333-1727
Mailing Address - Country:US
Mailing Address - Phone:860-739-3133
Mailing Address - Fax:860-739-3131
Practice Address - Street 1:314 FLANDERS RD
Practice Address - Street 2:SUITE 1B
Practice Address - City:EAST LYME
Practice Address - State:CT
Practice Address - Zip Code:06333-1727
Practice Address - Country:US
Practice Address - Phone:860-739-3133
Practice Address - Fax:860-739-3131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2007-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0073841223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1659376507OtherNPI FOR DR. KIRK ENGEL