Healthcare Provider Details

I. General information

NPI: 1043747116
Provider Name (Legal Business Name): MICHAEL THOMAS DEPASCALE DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2017
Last Update Date: 05/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 COW HILL RD
MYSTIC CT
06355-1449
US

IV. Provider business mailing address

1231 VAN BUREN DR
ANNAPOLIS MD
21403-2132
US

V. Phone/Fax

Practice location:
  • Phone: 860-536-9661
  • Fax:
Mailing address:
  • Phone: 201-906-5458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number11807
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: