Healthcare Provider Details

I. General information

NPI: 1881237402
Provider Name (Legal Business Name): CRAIG A. STASULIS DMD, MD, ORAL AND MAXILLOFACIAL SURGERY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2019
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 WILLARD AVE UNIT D
NEWINGTON CT
06111-2318
US

IV. Provider business mailing address

435 WILLARD AVE UNIT D
NEWINGTON CT
06111-2318
US

V. Phone/Fax

Practice location:
  • Phone: 860-796-1329
  • Fax:
Mailing address:
  • Phone: 860-796-1329
  • 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: DR. CRAIG ALLEN STASULIS
Title or Position: OWNER
Credential: DMD, MD
Phone: 860-500-7995