Provider Demographics
NPI:1063700037
Name:ORAL AND MAXILLOFACIAL SURGICAL ASSOCIATES, PC
Entity type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:SORRENTINO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-787-6581
Mailing Address - Street 1:1423 CHAPEL ST
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4411
Mailing Address - Country:US
Mailing Address - Phone:203-787-6581
Mailing Address - Fax:203-782-6389
Practice Address - Street 1:1423 CHAPEL ST
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4411
Practice Address - Country:US
Practice Address - Phone:203-787-6581
Practice Address - Fax:203-782-6389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT51391223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty