Provider Demographics
NPI:1619698628
Name:DOMBKOWSKI, SCOTT EDWARD
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:EDWARD
Last Name:DOMBKOWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 KERR RD
Mailing Address - Street 2:
Mailing Address - City:CANTERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06331-1205
Mailing Address - Country:US
Mailing Address - Phone:860-334-2020
Mailing Address - Fax:
Practice Address - Street 1:1007 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06241-2170
Practice Address - Country:US
Practice Address - Phone:860-457-4690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT082931835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT08293Medicaid