Healthcare Provider Details

I. General information

NPI: 1750070355
Provider Name (Legal Business Name): MARKELL BACOULIS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 POST RD E
WESTPORT CT
06880-5238
US

IV. Provider business mailing address

35 HILLTOP DR
SHELTON CT
06484-2126
US

V. Phone/Fax

Practice location:
  • Phone: 914-261-3518
  • Fax:
Mailing address:
  • Phone: 203-610-7104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: