Provider Demographics
NPI:1912928946
Name:CONNECTICUT VALLEY ORAL SURGERY ASSOCIATES, PC
Entity Type:Organization
Organization Name:CONNECTICUT VALLEY ORAL SURGERY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:EBBIGHAUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-357-3709
Mailing Address - Street 1:368 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301
Mailing Address - Country:US
Mailing Address - Phone:802-254-9418
Mailing Address - Fax:802-254-2563
Practice Address - Street 1:368 CANAL ST
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-6618
Practice Address - Country:US
Practice Address - Phone:802-254-9418
Practice Address - Fax:802-254-2563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2474Medicare ID - Type Unspecified