Healthcare Provider Details

I. General information

NPI: 1003947425
Provider Name (Legal Business Name): MARK S ROISMAN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

225 MAIN ST SUITE #304
WESTPORT CT
06880-3216
US

IV. Provider business mailing address

225 MAIN ST SUITE #304
WESTPORT CT
06880-3216
US

V. Phone/Fax

Practice location:
  • Phone: 203-227-6338
  • Fax:
Mailing address:
  • Phone: 203-227-6338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number008100
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: