Healthcare Provider Details

I. General information

NPI: 1679629489
Provider Name (Legal Business Name): MONROE HEYWARD RACKOW D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 TOLLAND TPKE SUITE 2A
MANCHESTER CT
06042-1771
US

IV. Provider business mailing address

360 TOLLAND TPKE SUITE 2A
MANCHESTER CT
06042-1771
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-4811
  • Fax: 860-645-0882
Mailing address:
  • Phone: 860-646-4811
  • Fax: 860-645-0882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number3929
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: