Healthcare Provider Details

I. General information

NPI: 1336271030
Provider Name (Legal Business Name): MITRA Y. KABAKOFF D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MAIN ST
UNIONVILLE CT
06085-1131
US

IV. Provider business mailing address

101 MAIN ST
UNIONVILLE CT
06085-1131
US

V. Phone/Fax

Practice location:
  • Phone: 860-673-3900
  • Fax: 860-673-0038
Mailing address:
  • Phone: 860-673-3900
  • Fax: 860-673-0038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9543
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: