Provider Demographics
NPI:1821008202
Name:MOLINE, STANISLAV (DMD, MDS)
Entity Type:Individual
Prefix:DR
First Name:STANISLAV
Middle Name:
Last Name:MOLINE
Suffix:
Gender:M
Credentials:DMD, MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029-0670
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 CHUCRH ST
Practice Address - Street 2:# 670
Practice Address - City:ELLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06029-0670
Practice Address - Country:US
Practice Address - Phone:860-000-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0094731223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics