1902904378 NPI number — ORAL AND MAXILLOFACIAL SURGEONS PC

Table of content: MR. JASON MICHAEL BURDGE CCDC, CBHCM, BHRS (NPI 1932400330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902904378 NPI number — ORAL AND MAXILLOFACIAL SURGEONS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORAL AND MAXILLOFACIAL SURGEONS PC
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:
1902904378
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:
20 WEST AVON ROAD
Provider Second Line Business Mailing Address:
AVON PROFESSIONAL CENTER
Provider Business Mailing Address City Name:
AVON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-675-4695
Provider Business Mailing Address Fax Number:
860-675-8583

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 SOUTH MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-347-6939
Provider Business Practice Location Address Fax Number:
860-347-7993
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SPERLING
Authorized Official First Name:
ARTHUR
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
860-347-6939

Provider Taxonomy Codes

  • Taxonomy code: 204E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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