Provider Demographics
NPI:1982811667
Name:ORAL AND MAXILLOFACIAL SURGEONS, P.C.
Entity Type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGEONS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HARRIET
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:SPERLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-347-6939
Mailing Address - Street 1:80 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3648
Mailing Address - Country:US
Mailing Address - Phone:860-347-6939
Mailing Address - Fax:860-347-7933
Practice Address - Street 1:80 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3648
Practice Address - Country:US
Practice Address - Phone:860-347-6939
Practice Address - Fax:860-347-7933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTD04158174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTT23278Medicare UPIN
CTT22691Medicare UPIN