Healthcare Provider Details

I. General information

NPI: 1790398428
Provider Name (Legal Business Name): CT OROFACIAL MYOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2020
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 MIXVILLE RD
CHESHIRE CT
06410-1968
US

IV. Provider business mailing address

384 MIXVILLE RD
CHESHIRE CT
06410-1968
US

V. Phone/Fax

Practice location:
  • Phone: 203-217-7090
  • Fax:
Mailing address:
  • Phone: 203-217-7090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code125K00000X
TaxonomyAdvanced Practice Dental Therapist
License Number
License Number State

VIII. Authorized Official

Name: BRITTNY ANN SCIARRA
Title or Position: OWNER
Credential: RDH
Phone: 203-217-7090