Healthcare Provider Details

I. General information

NPI: 1053782060
Provider Name (Legal Business Name): CONNECTICUT CENTER FOR ORAL FACIAL AND IMPLANT SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2015
Last Update Date: 10/17/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 S MAIN ST
WEST HARTFORD CT
06107-2408
US

IV. Provider business mailing address

80 S MAIN ST
WEST HARTFORD CT
06107-2408
US

V. Phone/Fax

Practice location:
  • Phone: 860-231-1030
  • Fax: 860-231-1032
Mailing address:
  • Phone: 860-231-1030
  • Fax: 860-231-1032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number011331
License Number StateCT

VIII. Authorized Official

Name: DR. JACOB MARSHALL GADY
Title or Position: PRESIDENT
Credential: D.M.D., M.D.
Phone: 860-231-1030