1235257148 NPI number — ORAL & MAXILLOFACIAL SURGERY ASSOCIATES OF GREATER NEW HAVEN, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235257148 NPI number — ORAL & MAXILLOFACIAL SURGERY ASSOCIATES OF GREATER NEW HAVEN, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORAL & MAXILLOFACIAL SURGERY ASSOCIATES OF GREATER NEW HAVEN, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235257148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
136 SHERMAN AVE
Provider Second Line Business Mailing Address:
SUITE #402
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06511-5238
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-865-0807
Provider Business Mailing Address Fax Number:
203-562-4922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
136 SHERMAN AVE
Provider Second Line Business Practice Location Address:
SUITE #402
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06511-5238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-865-0807
Provider Business Practice Location Address Fax Number:
203-562-4922
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SKOPE
Authorized Official First Name:
LEONARD
Authorized Official Middle Name:
WARREN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
203-865-0807

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  005198 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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