Provider Demographics
NPI:1417949405
Name:MEMBRINO, RALPH GERARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:GERARD
Last Name:MEMBRINO
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 1:571 WOLCOTT ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-1310
Mailing Address - Country:US
Mailing Address - Phone:203-753-9503
Mailing Address - Fax:203-755-4831
Practice Address - Street 1:571 WOLCOTT ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-1310
Practice Address - Country:US
Practice Address - Phone:203-753-9503
Practice Address - Fax:203-755-4831
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-17
Last Update Date:2007-07-08
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-10
Provider Licenses
StateLicense IDTaxonomies
CT58051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
T22163Medicare ID - Type Unspecified