Healthcare Provider Details

I. General information

NPI: 1730506700
Provider Name (Legal Business Name): CONNECTICUT SURGICAL ARTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 SACHEM ST
NORWICH CT
06360-4144
US

IV. Provider business mailing address

159 SACHEM ST
NORWICH CT
06360-4144
US

V. Phone/Fax

Practice location:
  • Phone: 860-885-0444
  • Fax: 860-885-0816
Mailing address:
  • Phone: 860-885-0444
  • Fax: 860-885-0816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD J. MARTIN
Title or Position: DIRECTOR
Credential: M.D., D.M.D.
Phone: 860-885-0444