Provider Demographics
NPI:1992122956
Name:BRISTOL ORAL SURGERY & IMPLANT CENTER
Entity type:Organization
Organization Name:BRISTOL ORAL SURGERY & IMPLANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:860-538-3495
Mailing Address - Street 1:33 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-5820
Mailing Address - Country:US
Mailing Address - Phone:860-538-3495
Mailing Address - Fax:860-645-0349
Practice Address - Street 1:33 HIGH ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-5820
Practice Address - Country:US
Practice Address - Phone:860-538-3495
Practice Address - Fax:860-645-0349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT98121223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty