Healthcare Provider Details

I. General information

NPI: 1750158564
Provider Name (Legal Business Name): RAMY SHAKER WISA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 FEDERAL RD STE B11
BROOKFIELD CT
06804-2651
US

IV. Provider business mailing address

246 FEDERAL RD STE B11
BROOKFIELD CT
06804-2651
US

V. Phone/Fax

Practice location:
  • Phone: 203-790-0111
  • Fax:
Mailing address:
  • Phone: 203-790-0111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14808
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: