Healthcare Provider Details

I. General information

NPI: 1073633426
Provider Name (Legal Business Name): GREENWICH ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 MAPLE AVE
GREENWICH CT
06830-5620
US

IV. Provider business mailing address

23 MAPLE AVE
GREENWICH CT
06830-5620
US

V. Phone/Fax

Practice location:
  • Phone: 203-661-5858
  • Fax: 203-661-1159
Mailing address:
  • Phone: 203-661-5858
  • Fax: 203-661-1159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number049719-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number009552
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7023
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number040760
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6237
License Number StateCT
# 6
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number033181
License Number StateNY

VIII. Authorized Official

Name: DR. STEVEN M BRODY
Title or Position: PRESIDENT
Credential: DDS
Phone: 203-661-5858