Healthcare Provider Details

I. General information

NPI: 1770406035
Provider Name (Legal Business Name): CONNECTICUT ORAL & MAXILLOFACIAL SURGERY CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 S BROAD ST STE 2A
MERIDEN CT
06450-6601
US

IV. Provider business mailing address

546 S BROAD ST STE 2A
MERIDEN CT
06450-6601
US

V. Phone/Fax

Practice location:
  • Phone: 203-639-0800
  • Fax:
Mailing address:
  • Phone: 203-639-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAELA MUNIZ
Title or Position: VP, PAYOR RELATIONS
Credential:
Phone: 469-324-3242