Healthcare Provider Details

I. General information

NPI: 1154418531
Provider Name (Legal Business Name): GARY S RAPPAPORT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HALL DR
ORANGE CT
06477-2543
US

IV. Provider business mailing address

80 PHOENIX AVE STE 201
WATERBURY CT
06702-1418
US

V. Phone/Fax

Practice location:
  • Phone: 203-795-6621
  • Fax:
Mailing address:
  • Phone: 203-756-8021
  • Fax: 203-597-8860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3841
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: