Healthcare Provider Details

I. General information

NPI: 1215152574
Provider Name (Legal Business Name): NORTHEAST IMPLANT & ORAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 HOSPITAL AVE STE 306
DANBURY CT
06810-5961
US

IV. Provider business mailing address

27 HOSPITAL AVE STE 306
DANBURY CT
06810-5961
US

V. Phone/Fax

Practice location:
  • Phone: 203-797-0008
  • Fax: 203-743-7822
Mailing address:
  • Phone: 203-628-4450
  • Fax: 203-628-2350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: MONICA MCCARLEY
Title or Position: INSURANCE COORDINATOR/CREDENTIALING
Credential:
Phone: 203-628-4450