Healthcare Provider Details

I. General information

NPI: 1417155276
Provider Name (Legal Business Name): FACIAL COSMETIC & MAXILLOFACIAL SURGERY P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 N MAIN ST SUITE 202
EAST LONGMEADOW MA
01028-1828
US

IV. Provider business mailing address

382 N MAIN ST SUITE 202
EAST LONGMEADOW MA
01028-1828
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number016684
License Number StateMA

VIII. Authorized Official

Name: RICHARD J FRAZIERO
Title or Position: PRESIDENT
Credential: DMD F.A.D.S.A
Phone: 413-525-0100