Healthcare Provider Details

I. General information

NPI: 1811387863
Provider Name (Legal Business Name): WEST HARTFORD ORAL AND IMPLANT SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2015
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
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 TURNPIKE WEST SUITE 102
MANCHESTER CT
06040-3864
US

V. Phone/Fax

Practice location:
  • Phone: 860-649-2272
  • Fax: 860-533-1010
Mailing address:
  • Phone: 860-232-4606
  • Fax: 860-233-8359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number009050
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: LISA HARRISON
Title or Position: BUSINESS MANAGER
Credential:
Phone: 860-646-2272