Provider Demographics
NPI:1043237704
Name:MACK, ALPHONSO L (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALPHONSO
Middle Name:L
Last Name:MACK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WINTONBURY MALL
Mailing Address - Street 2:BUILDING #5
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-2466
Mailing Address - Country:US
Mailing Address - Phone:860-243-5451
Mailing Address - Fax:860-656-6107
Practice Address - Street 1:2 WINTONBURY MALL
Practice Address - Street 2:BUILDING #5
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2466
Practice Address - Country:US
Practice Address - Phone:860-243-5451
Practice Address - Fax:860-656-6107
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0058451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002058451 00Medicaid
CT002058451 00Medicaid