Basic Information
| Provider Information | |||||||||
| NPI: | 1881183721 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY DENTISTS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ORAL MAXILLOFACIAL SURGERY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060303905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606792207 | ||||||||
| FaxNumber: | 8606791899 | ||||||||
| Practice Location | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060300001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606793300 | ||||||||
| FaxNumber: | 8606791702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2018 | ||||||||
| LastUpdateDate: | 05/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | ATKINS | ||||||||
| AuthorizedOfficialFirstName: | ELLIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING CONTACT | ||||||||
| AuthorizedOfficialTelephone: | 8606792207 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.