Provider Demographics
NPI:1881237402
Name:CRAIG A. STASULIS DMD, MD, ORAL AND MAXILLOFACIAL SURGERY, INC
Entity type:Organization
Organization Name:CRAIG A. STASULIS DMD, MD, ORAL AND MAXILLOFACIAL SURGERY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:STASULIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:860-500-7995
Mailing Address - Street 1:435 WILLARD AVE UNIT D
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2318
Mailing Address - Country:US
Mailing Address - Phone:860-796-1329
Mailing Address - Fax:
Practice Address - Street 1:435 WILLARD AVE UNIT D
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2318
Practice Address - Country:US
Practice Address - Phone:860-796-1329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-27
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty