Healthcare Provider Details

I. General information

NPI: 1104183409
Provider Name (Legal Business Name): CENTRAL CTONNECTICUT ORAL MAXILLOFACIAL& IMPLANT SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2012
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 FARMINGTON AVE SUITE 223
WEST HARTFORD CT
06119-1505
US

IV. Provider business mailing address

836 FARMINGTON AVE SUITE 223
WEST HARTFORD CT
06119-1505
US

V. Phone/Fax

Practice location:
  • Phone: 860-586-8507
  • Fax: 860-586-8697
Mailing address:
  • Phone: 860-586-8507
  • Fax: 860-586-8697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. JOSEPH R HOWARD
Title or Position: ORAL SURGEON
Credential: D.D.S., M.D.
Phone: 860-586-8507