Healthcare Provider Details

I. General information

NPI: 1407051238
Provider Name (Legal Business Name): WEST HARTFORD MAXILLOFACIAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 FARMINGTON AVE
WEST HARTFORD CT
06107-2227
US

IV. Provider business mailing address

928 FARMINGTON AVE
WEST HARTFORD CT
06107-2227
US

V. Phone/Fax

Practice location:
  • Phone: 860-232-4606
  • Fax: 860-233-8352
Mailing address:
  • Phone: 860-232-4606
  • Fax: 860-233-8352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number008367
License Number StateCT

VIII. Authorized Official

Name: DR. YOLANDA P FRONTERA
Title or Position: PRESIDENT
Credential: DDS, MDS
Phone: 860-232-4606