=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538207147
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRAIG MEGIBOW DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 FEDERAL RD SUITE 103
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06804-2412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-775-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 FEDERAL RD SUITE 103
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06804-2412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-775-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 008793
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------