=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437031101
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRFIELD OMS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2025
-----------------------------------------------------
Last Update Date | 07/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 760 KINGS HWY W BLDG B
-----------------------------------------------------
City | SOUTHPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06890-3102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-259-2227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 760 KINGS HWY W BLDG B
-----------------------------------------------------
City | SOUTHPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06890-3102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-259-2227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | CHAD HENDRICKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-859-0444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------