Healthcare Provider Details

I. General information

NPI: 1285655217
Provider Name (Legal Business Name): CONNECTICUT VALLEY ORAL SURGERY ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 HIGH ST
GREENFIELD MA
01301-2608
US

IV. Provider business mailing address

285 HIGH ST
GREENFIELD MA
01301-2608
US

V. Phone/Fax

Practice location:
  • Phone: 413-774-2961
  • Fax: 413-773-3076
Mailing address:
  • Phone: 413-774-2961
  • Fax: 413-773-3076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: CANDY EBBIGHAUSEN
Title or Position: ADMINISTRATOR
Credential:
Phone: 603-357-3709