=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790398428
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CT OROFACIAL MYOLOGY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2020
-----------------------------------------------------
Last Update Date | 09/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 384 MIXVILLE RD
-----------------------------------------------------
City | CHESHIRE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06410-1968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-217-7090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 384 MIXVILLE RD
-----------------------------------------------------
City | CHESHIRE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06410-1968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-217-7090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRITTNY ANN SCIARRA
-----------------------------------------------------
Credential | RDH
-----------------------------------------------------
Telephone | 203-217-7090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 125K00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Dental Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------