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General NPI Number Information
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NPI Number | 1861920068
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Entity Type | Organization
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Legal Business Name | MOFS-CT ORAL FACIAL SURGERY LLC
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Dates
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Enumeration Date | 06/01/2017
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Last Update Date | 06/01/2017
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Provider Practice Location Address
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Address Line | 1 BOULDER AVE
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City | OLD GREENWICH
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State | CT
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Zip | 06870-1420
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Country | US
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Telephone | 203-990-3300
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Fax | 212-202-6447
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Provider Business Mailing Address
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Address Line | 6118 RIVERDALE AVE
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City | BRONX
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State | NY
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Zip | 10471-1009
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Country | US
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Telephone | 203-998-7470
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Fax | 212-202-6447
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. JANET C BODEY
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Credential | DDS
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Telephone | 203-998-7470
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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 | 9973
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License Number State | CT
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