=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457262149
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONNECTICUT ORAL & MAXILLOFACIAL SURGERY CENTERS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2026
-----------------------------------------------------
Last Update Date | 09/14/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 WASHINGTON AVE
-----------------------------------------------------
City | NORTH HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06473-1721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-239-7181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 116 WASHINGTON AVE
-----------------------------------------------------
City | NORTH HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06473-1721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-239-7181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, PAYOR RELATIONS
-----------------------------------------------------
Name | MICHAELA MUNIZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-324-3242
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------