Provider Demographics
NPI:1609154830
Name:BAK, MIRINAE (DDS)
Entity Type:Individual
Prefix:
First Name:MIRINAE
Middle Name:
Last Name:BAK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 CLOVE BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL JUNCTION
Mailing Address - State:NY
Mailing Address - Zip Code:12533-5221
Mailing Address - Country:US
Mailing Address - Phone:845-242-3132
Mailing Address - Fax:
Practice Address - Street 1:450 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-3551
Practice Address - Country:US
Practice Address - Phone:860-223-2424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0105881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice