Provider Demographics
NPI:1215152574
Name:NORTHEAST IMPLANT & ORAL SURGERY, PC
Entity type:Organization
Organization Name:NORTHEAST IMPLANT & ORAL SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-628-4450
Mailing Address - Street 1:27 HOSPITAL AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5961
Mailing Address - Country:US
Mailing Address - Phone:203-628-4450
Mailing Address - Fax:203-628-2350
Practice Address - Street 1:27 HOSPITAL AVE STE 306
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5961
Practice Address - Country:US
Practice Address - Phone:203-797-0008
Practice Address - Fax:203-743-7822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD68401Medicare ID - Type Unspecified