Provider Demographics
NPI:1215123807
Name:NORWICH ORAL & MAXILLOFACIAL SURGEONS, PC
Entity type:Organization
Organization Name:NORWICH ORAL & MAXILLOFACIAL SURGEONS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:KEENEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-886-0651
Mailing Address - Street 1:130 NEW LONDON TPKE
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2624
Mailing Address - Country:US
Mailing Address - Phone:860-886-0651
Mailing Address - Fax:860-823-1577
Practice Address - Street 1:130 NEW LONDON TPKE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2624
Practice Address - Country:US
Practice Address - Phone:860-886-0651
Practice Address - Fax:860-823-1577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004083333Medicaid
CT004083333Medicaid