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General NPI Number Information
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NPI Number | 1518794338
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Entity Type | Organization
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Legal Business Name | PREMIER ORAL SURGERY AND IMPLANTOLOGY CENTER LLC
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Dates
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Enumeration Date | 09/16/2024
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Last Update Date | 09/16/2024
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Provider Practice Location Address
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Address Line | 211 E PUTNAM AVE STE 2-6
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City | COS COB
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State | CT
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Zip | 06807-2734
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Country | US
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Telephone | 203-303-9693
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Fax |
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Provider Business Mailing Address
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Address Line | 346 MAIN AVE STE H
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City | NORWALK
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State | CT
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Zip | 06851-6406
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Country | US
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Telephone | 203-939-9390
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. SIMON BANGIYEV
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Credential | DDS, MD
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Telephone | 203-303-9693
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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