Healthcare Provider Details

I. General information

NPI: 1720520976
Provider Name (Legal Business Name): STAMFORD ORAL AND MAXILLOFACIAL SURGICAL ARTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 BRIDGE ST
STAMFORD CT
06905-4501
US

IV. Provider business mailing address

27 BRIDGE ST
STAMFORD CT
06905-4501
US

V. Phone/Fax

Practice location:
  • Phone: 203-325-2661
  • Fax:
Mailing address:
  • Phone: 203-325-2661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number009711
License Number StateCT

VIII. Authorized Official

Name: DR. NAUSHAD EDIBAM
Title or Position: MEMBER
Credential:
Phone: 203-325-2661