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General NPI Number Information
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NPI Number | 1861939456
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Entity Type | Organization
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Legal Business Name | SIMON BANGIYEV DDS, MD, PC DBA PREMIER ORAL SURGERY
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Dates
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Enumeration Date | 01/20/2017
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Last Update Date | 01/20/2017
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Provider Practice Location Address
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Address Line | 346 MAIN AVE SUITE H
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City | NORWALK
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State | CT
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Zip | 06851-1592
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Country | US
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Telephone | 203-939-9390
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Fax |
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Provider Business Mailing Address
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Address Line | 346 MAIN AVE SUITE H
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City | NORWALK
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State | CT
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Zip | 06851-1592
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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 | PRESIDENT
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Name | DR. SIMON Y BANGIYEV
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Credential | DDS, MD
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Telephone | 203-939-9390
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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 | 011114
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License Number State | CT
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