Provider Demographics
NPI:1487692174
Name:FAIRFIELD ORAL SURGERY, LLC
Entity type:Organization
Organization Name:FAIRFIELD ORAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:EVAN
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:MS, DDS
Authorized Official - Phone:203-259-2227
Mailing Address - Street 1:1305 POST RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6016
Mailing Address - Country:US
Mailing Address - Phone:203-259-2227
Mailing Address - Fax:203-259-2218
Practice Address - Street 1:1305 POST RD
Practice Address - Street 2:SUITE 303
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6016
Practice Address - Country:US
Practice Address - Phone:203-259-2227
Practice Address - Fax:203-259-2218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9276261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental