Provider Demographics
NPI:1477580538
Name:BOCCALATTE, MICHELE SALONIA (DMD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:SALONIA
Last Name:BOCCALATTE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:
Other - Last Name:SALONIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:955 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-5153
Mailing Address - Country:US
Mailing Address - Phone:860-346-6737
Mailing Address - Fax:860-704-0239
Practice Address - Street 1:955 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-5153
Practice Address - Country:US
Practice Address - Phone:860-346-6737
Practice Address - Fax:860-704-0239
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT56461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCT5646OtherCT LISCENSE NUMBER
CT061065268OtherPROVIDER IDENTIFICATION