Healthcare Provider Details

I. General information

NPI: 1124087903
Provider Name (Legal Business Name): EUGEN GUSTAV WICHMANN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITING ST STE 2C
PLAINVILLE CT
06062-2262
US

IV. Provider business mailing address

55 WHITING ST STE 2C
PLAINVILLE CT
06062-2262
US

V. Phone/Fax

Practice location:
  • Phone: 860-747-5529
  • Fax: 860-747-5520
Mailing address:
  • Phone: 860-747-5529
  • Fax: 860-747-5520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number008412
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: