Provider Demographics
NPI:1952898025
Name:PREMIER ORAL SURGERY AND IMPLANTOLOGY CENTER LLC
Entity Type:Organization
Organization Name:PREMIER ORAL SURGERY AND IMPLANTOLOGY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:Y
Authorized Official - Last Name:BANGIYEV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:203-690-1960
Mailing Address - Street 1:411 BARNUM AVENUE CUTOFF STE 5
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-5100
Mailing Address - Country:US
Mailing Address - Phone:203-960-1960
Mailing Address - Fax:
Practice Address - Street 1:411 BARNUM AVENUE CUTOFF STE 5
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-5100
Practice Address - Country:US
Practice Address - Phone:203-960-1960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-15
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT111141223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty