Provider Demographics
NPI:1285651133
Name:CONNECTICUT MAXILLOFACIAL SURGEONS, LLC
Entity type:Organization
Organization Name:CONNECTICUT MAXILLOFACIAL SURGEONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING & INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SCHANTAL
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:THIELKE
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:860-678-7528
Mailing Address - Street 1:291 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1925
Mailing Address - Country:US
Mailing Address - Phone:860-678-7528
Mailing Address - Fax:860-678-7933
Practice Address - Street 1:291 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1925
Practice Address - Country:US
Practice Address - Phone:860-678-7528
Practice Address - Fax:860-678-7933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty