Healthcare Provider Details

I. General information

NPI: 1487692174
Provider Name (Legal Business Name): FAIRFIELD ORAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 POST RD SUITE 303
FAIRFIELD CT
06824-6016
US

IV. Provider business mailing address

1305 POST RD SUITE 303
FAIRFIELD CT
06824-6016
US

V. Phone/Fax

Practice location:
  • Phone: 203-259-2227
  • Fax: 203-259-2218
Mailing address:
  • Phone: 203-259-2227
  • Fax: 203-259-2218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number9276
License Number StateCT

VIII. Authorized Official

Name: DR. TODD EVAN BLOOM
Title or Position: PRESIDENT
Credential: M.S., D.D.S.
Phone: 203-259-2227