Provider Demographics
NPI:1679554513
Name:SMULLIN, STEVEN EDWARD (DMD, MD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:EDWARD
Last Name:SMULLIN
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 BROOKHOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-1014
Mailing Address - Country:US
Mailing Address - Phone:617-230-1152
Mailing Address - Fax:
Practice Address - Street 1:10 SOUTH ST STE 202
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877-4125
Practice Address - Country:US
Practice Address - Phone:203-403-3686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT102461223S0112X
MA231511204E00000X
MA205711223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110076671AMedicaid
MA000171401Medicare PIN