Provider Demographics
NPI:1043366354
Name:STATKEVICH, JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:STATKEVICH
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 1:71 BRIDLEPATH DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-4043
Mailing Address - Country:US
Mailing Address - Phone:860-628-6677
Mailing Address - Fax:
Practice Address - Street 1:80 PHOENIX AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1418
Practice Address - Country:US
Practice Address - Phone:203-574-3343
Practice Address - Fax:203-574-5488
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0077341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice