Healthcare Provider Details

I. General information

NPI: 1083173538
Provider Name (Legal Business Name): RIDGEFIELD ORAL AND MAXILLOFACIAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SOUTH ST STE 202
RIDGEFIELD CT
06877-4125
US

IV. Provider business mailing address

87 BROOKHOLLOW LN
STAMFORD CT
06902-1014
US

V. Phone/Fax

Practice location:
  • Phone: 203-403-3686
  • Fax:
Mailing address:
  • Phone: 617-230-1152
  • 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. STEVEN EDWARD SMULLIN
Title or Position: OWNER
Credential: DMD, MD
Phone: 203-403-3686