MEDICARE: MIRINAE BAK D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	010588	CT

General Provider Information

NPI Number	:	1609154830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRINAE BAK D.D.S

Provider Business Mailing Address
First Line	:	53 CLOVE BRANCH RD
Second Line	:
City	:	HOPEWELL JUNCTION
State	:	NY
Zip	:	12533-5221
Country	:	US
Telephone Number	:	845-242-3132
Fax Number	:

Provider Business Practice Location Address
First Line	:	450 S MAIN ST
Second Line	:
City	:	NEW BRITAIN
State	:	CT
Zip	:	06051-3551
Country	:	US
Telephone Number	:	860-223-2424
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2011
Last Update Date	:	07/21/2011

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