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General NPI Number Information
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NPI Number | 1952898025
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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 | 04/15/2018
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Last Update Date | 04/16/2018
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Provider Practice Location Address
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Address Line | 411 BARNUM AVENUE CUTOFF STE 5
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City | STRATFORD
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State | CT
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Zip | 06614-5100
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Country | US
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Telephone | 203-960-1960
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Fax |
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Provider Business Mailing Address
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Address Line | 411 BARNUM AVENUE CUTOFF STE 5
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City | STRATFORD
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State | CT
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Zip | 06614-5100
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Country | US
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Telephone | 203-960-1960
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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 | 203-690-1960
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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 | 11114
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License Number State | CT
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