Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 007846 | CT |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 007846 | CT |
NPI | 1407851116 |
---|---|
Provider Name | Michael T Goupil |
First Address | Farmington, CT 06030-3915 |
Second Address | Farmington, CT 06030-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/06/2005 |
Last Update Date | 12/04/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2078469 | (05) | CT |
U35215 | (02) | CT |