1639508740 NPI number — MARKOWSKI DENTAL ASSOCIATES P C

Table of content: MR. RAYMOND GLENN VARNUM RPH (NPI 1043263874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639508740 NPI number — MARKOWSKI DENTAL ASSOCIATES P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARKOWSKI DENTAL ASSOCIATES P C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1639508740
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
162 MOUNTAIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUFFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06078-2091
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-668-0241
Provider Business Mailing Address Fax Number:
860-668-8788

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
162 MOUNTAIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUFFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06078-2091
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-668-0241
Provider Business Practice Location Address Fax Number:
860-668-8788
Provider Enumeration Date:
11/08/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TROFIMOV
Authorized Official First Name:
SIMONA
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
860-668-0241

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  010306 , 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: 008001796 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008020155 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008040008 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".