Healthcare Provider Details

I. General information

NPI: 1083602916
Provider Name (Legal Business Name): ROBERT J MAILLOUX D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

397 NEW BRITAIN AVE
HARTFORD CT
06106-3833
US

IV. Provider business mailing address

112 COUTURE DR
BRISTOL CT
06010-3317
US

V. Phone/Fax

Practice location:
  • Phone: 860-247-1021
  • Fax: 860-724-2379
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5868
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: