Healthcare Provider Details

I. General information

NPI: 1033107040
Provider Name (Legal Business Name): MICHEAL ROGER MARCOTTE DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 CENTER ST
BRISTOL CT
06010-4916
US

IV. Provider business mailing address

5 CENTER ST
BRISTOL CT
06010-4916
US

V. Phone/Fax

Practice location:
  • Phone: 860-589-3316
  • Fax: 860-584-8976
Mailing address:
  • Phone: 860-589-3316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4301
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: