Healthcare Provider Details

I. General information

NPI: 1134716640
Provider Name (Legal Business Name): MAXILLOFACIAL & IMPLANT SURGERY OF WESTERN MASS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2020
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 N MAIN ST STE 202
EAST LONGMEADOW MA
01028-1830
US

IV. Provider business mailing address

382 N MAIN ST STE 202
EAST LONGMEADOW MA
01028-1830
US

V. Phone/Fax

Practice location:
  • Phone: 413-525-0100
  • Fax: 413-525-8608
Mailing address:
  • Phone: 413-525-1000
  • Fax: 413-525-8608

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 D NGUYEN
Title or Position: SURGEON
Credential: DMD, MD
Phone: 413-525-0100