Provider Demographics
NPI:1679761142
Name:SHORELINE ORAL & MAXILLOFACIAL SURGEONS, PC
Entity type:Organization
Organization Name:SHORELINE ORAL & MAXILLOFACIAL SURGEONS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:KRESSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-388-5745
Mailing Address - Street 1:1480 BOSTON POST ROAD
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-1750
Mailing Address - Country:US
Mailing Address - Phone:860-388-5745
Mailing Address - Fax:860-388-2145
Practice Address - Street 1:1480 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-1750
Practice Address - Country:US
Practice Address - Phone:860-388-5745
Practice Address - Fax:860-388-2145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE79201223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU42000Medicare UPIN