Healthcare Provider Details

I. General information

NPI: 1417949405
Provider Name (Legal Business Name): RALPH GERARD MEMBRINO D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/23/2006
Reactivation Date: 04/10/2006

III. Provider practice location address

571 WOLCOTT ST
WATERBURY CT
06705-1310
US

IV. Provider business mailing address

571 WOLCOTT ST
WATERBURY CT
06705-1310
US

V. Phone/Fax

Practice location:
  • Phone: 203-753-9503
  • Fax: 203-755-4831
Mailing address:
  • Phone: 203-753-9503
  • Fax: 203-755-4831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5805
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: