Healthcare Provider Details

I. General information

NPI: 1285651133
Provider Name (Legal Business Name): CONNECTICUT MAXILLOFACIAL SURGEONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

291 FARMINGTON AVE
FARMINGTON CT
06032-1925
US

IV. Provider business mailing address

291 FARMINGTON AVE
FARMINGTON CT
06032-1925
US

V. Phone/Fax

Practice location:
  • Phone: 860-678-7528
  • Fax: 860-678-7933
Mailing address:
  • Phone: 860-678-7528
  • Fax: 860-678-7933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SCHANTAL MARY THIELKE
Title or Position: BILLING & INSURANCE MANAGER
Credential: RDA
Phone: 860-678-7528