=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124379151
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DUSTIN F RABINE PP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2012
-----------------------------------------------------
Last Update Date | 10/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7365 MAIN ST
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06614-1300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-375-1932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7365 MAIN ST
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06614-1300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-375-1932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DUSTIN RABINE
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 203-375-1932
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 009910
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------