Healthcare Provider Details

I. General information

NPI: 1184634313
Provider Name (Legal Business Name): ORAL SURGERY ASSOCIATES, L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 10/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4747 MAIN ST
BRIDGEPORT CT
06606-1804
US

IV. Provider business mailing address

4747 MAIN STREET
BRIDGEPORT CT
06606
US

V. Phone/Fax

Practice location:
  • Phone: 203-371-5595
  • Fax:
Mailing address:
  • Phone: 203-371-5595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4982
License Number StateCT

VIII. Authorized Official

Name: MRS. STACEY L WHELAN
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 203-371-5595