Provider Demographics
NPI:1720520976
Name:STAMFORD ORAL AND MAXILLOFACIAL SURGICAL ARTS LLC
Entity Type:Organization
Organization Name:STAMFORD ORAL AND MAXILLOFACIAL SURGICAL ARTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:NAUSHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:EDIBAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-325-2661
Mailing Address - Street 1:27 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-4501
Mailing Address - Country:US
Mailing Address - Phone:203-325-2661
Mailing Address - Fax:
Practice Address - Street 1:27 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-4501
Practice Address - Country:US
Practice Address - Phone:203-325-2661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009711261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery