Basic Information
| Provider Information | |||||||||
| NPI: | 1861939456 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIMON BANGIYEV DDS, MD, PC DBA PREMIER ORAL SURGERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 346 MAIN AVE | ||||||||
| Address2: | SUITE H | ||||||||
| City: | NORWALK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068511592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039399390 | ||||||||
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| Practice Location | |||||||||
| Address1: | 346 MAIN AVE | ||||||||
| Address2: | SUITE H | ||||||||
| City: | NORWALK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068511592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039399390 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2017 | ||||||||
| LastUpdateDate: | 01/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | BANGIYEV | ||||||||
| AuthorizedOfficialFirstName: | SIMON | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2039399390 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS, MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 011114 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.