Healthcare Provider Details

I. General information

NPI: 1407455538
Provider Name (Legal Business Name): NEW: GLASTONBURY ORAL AND IMPLANT SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 06/16/2025
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 NEW LONDON TURNPIKE
GLASTONBURY CT
06033-7042
US

IV. Provider business mailing address

483 MIDDLE TPKE W STE 102
MANCHESTER CT
06040-3864
US

V. Phone/Fax

Practice location:
  • Phone: 860-659-2623
  • Fax:
Mailing address:
  • Phone: 860-649-2272
  • Fax: 860-533-1010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. RYAZ ANSARI
Title or Position: OWNER/OMS
Credential: D.D.S.
Phone: 860-649-0227