Provider Demographics
NPI:1972798338
Name:ORAL & MAXILLOFACIAL SURGEONS OF CENTRAL CT PC
Entity type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGEONS OF CENTRAL CT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:SLATER
Authorized Official - Last Name:ROZEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-235-6339
Mailing Address - Street 1:546 SOUTH BROAD ST
Mailing Address - Street 2:SUITE 4F
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450
Mailing Address - Country:US
Mailing Address - Phone:203-235-6339
Mailing Address - Fax:203-235-6339
Practice Address - Street 1:546 SOUTH BROAD ST
Practice Address - Street 2:SUITE 4F
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450
Practice Address - Country:US
Practice Address - Phone:203-235-6339
Practice Address - Fax:203-235-6339
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORAL & MAXILLOFACIAL SURGEONS OF CENTRAL CT PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3716204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTT22517Medicare PIN