Healthcare Provider Details

I. General information

NPI: 1134240922
Provider Name (Legal Business Name): COLUMBIA ORAL MAXILLOFACIAL IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

483 MIDDLE TPKE W
MANCHESTER CT
06040-3863
US

IV. Provider business mailing address

483 MIDDLE TPKE W
MANCHESTER CT
06040-3863
US

V. Phone/Fax

Practice location:
  • Phone: 860-645-0111
  • Fax:
Mailing address:
  • Phone: 860-645-0111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: BIBI KHAN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 860-645-0111