Healthcare Provider Details

I. General information

NPI: 1366651663
Provider Name (Legal Business Name): GARY EDWARD HORBLITT MAXILLOPROSTHODONTIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2226 BLACK ROCK TPKE
FAIRFIELD CT
06825
US

IV. Provider business mailing address

2226 BLACK ROCK TPKE
FAIRFIELD CT
06825
US

V. Phone/Fax

Practice location:
  • Phone: 203-366-7600
  • Fax: 203-366-6287
Mailing address:
  • Phone: 203-366-7600
  • Fax: 203-366-6287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number005838
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: