1417949405 NPI number — DR. RALPH GERARD MEMBRINO D.M.D.

Table of content: DR. RALPH GERARD MEMBRINO D.M.D. (NPI 1417949405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417949405 NPI number — DR. RALPH GERARD MEMBRINO D.M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEMBRINO
Provider First Name:
RALPH
Provider Middle Name:
GERARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.M.D.
Provider Gender Code:
M

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:
1417949405
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/23/2006
NPI Reactivation Date:
04/10/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
571 WOLCOTT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06705-1310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-753-9503
Provider Business Mailing Address Fax Number:
203-755-4831

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
571 WOLCOTT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06705-1310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-753-9503
Provider Business Practice Location Address Fax Number:
203-755-4831
Provider Enumeration Date:
08/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5805 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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