Provider Demographics
NPI:1407851116
Name:GOUPIL, MICHAEL T (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:GOUPIL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:MC3915
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-3915
Mailing Address - Country:US
Mailing Address - Phone:860-679-2808
Mailing Address - Fax:860-679-1330
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-3300
Practice Address - Fax:860-679-1099
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007846204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2078469Medicaid
CTU35215Medicare UPIN
CT190001013Medicare PIN