Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 008507 | CT |
NPI | 1255468005 |
---|---|
Provider Name | Dr. Jack D Degrado |
First Address | Stamford, CT 06905-5316 |
Second Address | Stamford, CT 06905-5316 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/02/2007 |
Last Update Date | 08/07/2007 |