Healthcare Provider Details

I. General information

NPI: 1821339086
Provider Name (Legal Business Name): HARTFORD COUNTY ORAL MAXILLOFACIAL & IMPLANT SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2013
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 FARMINGTON AVE SUITE 1
BRISTOL CT
06010-3969
US

IV. Provider business mailing address

259 FARMINGTON AVE SUITE 1
BRISTOL CT
06010-3969
US

V. Phone/Fax

Practice location:
  • Phone: 860-583-6549
  • Fax: 860-582-1547
Mailing address:
  • Phone: 860-583-6549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10729
License Number StateCT

VIII. Authorized Official

Name: DR. EAN JAMES
Title or Position: PRESIDENT
Credential: D.M.D., M.D
Phone: 856-361-6703