Healthcare Provider Details

I. General information

NPI: 1225146707
Provider Name (Legal Business Name): DR. MADLENE ESKAROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 ROOSEVELT AVE
MYSTIC CT
06355
US

IV. Provider business mailing address

12 ROOSEVELT AVE
MYSTIC CT
06355
US

V. Phone/Fax

Practice location:
  • Phone: 860-572-0593
  • Fax: 860-572-0595
Mailing address:
  • Phone: 860-572-0593
  • Fax: 860-572-0595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number009018
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number009018
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: