1558323428 NPI number — DR. LAURA C DAKE-ROCHE O.D.

Table of content: DR. LAURA C DAKE-ROCHE O.D. (NPI 1558323428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558323428 NPI number — DR. LAURA C DAKE-ROCHE O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAKE-ROCHE
Provider First Name:
LAURA
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

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:
1558323428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1950 OLD GALLOWS RD STE 520
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIENNA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22182-3970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-847-8899
Provider Business Mailing Address Fax Number:
571-223-6780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
58 MAPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAUGATUCK
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06770-4160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-729-2226
Provider Business Practice Location Address Fax Number:
203-729-2227
Provider Enumeration Date:
04/05/2006

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: 152W00000X , with the licence number:  002072 , 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)

  • Identifier: 004081387 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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