Healthcare Provider Details

I. General information

NPI: 1851395719
Provider Name (Legal Business Name): MARK S COHEN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 FEDERAL RD
BROOKFIELD CT
06804-1144
US

IV. Provider business mailing address

940 FEDERAL RD
BROOKFIELD CT
06804-1144
US

V. Phone/Fax

Practice location:
  • Phone: 203-775-5533
  • Fax: 203-775-5511
Mailing address:
  • Phone: 203-775-5533
  • Fax: 203-775-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4880
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: