Healthcare Provider Details

I. General information

NPI: 1497774152
Provider Name (Legal Business Name): RYAZ ANSARI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

483 MIDDLE TPKE W SUITE 102
MANCHESTER CT
06040-3863
US

IV. Provider business mailing address

483 MIDDLE TPKE W SUITE 102
MANCHESTER CT
06040-3863
US

V. Phone/Fax

Practice location:
  • Phone: 860-649-2272
  • Fax: 860-649-4538
Mailing address:
  • Phone: 860-649-2272
  • Fax: 860-649-4538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number009050
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: