Provider Demographics
NPI:1477543767
Name:BEVILACQUA, RICHARD G (DMD, MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:G
Last Name:BEVILACQUA
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71A NAUBUC AVE
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2006
Mailing Address - Country:US
Mailing Address - Phone:860-633-3519
Mailing Address - Fax:860-633-3510
Practice Address - Street 1:71A NAUBUC AVE
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2006
Practice Address - Country:US
Practice Address - Phone:860-633-3519
Practice Address - Fax:860-633-3510
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0080061223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTF84844Medicare UPIN