Provider Demographics
NPI:1487730297
Name:MASSICOTTE, ALLEN O (DDS)
Entity type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:O
Last Name:MASSICOTTE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 HIGHLAND AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708
Mailing Address - Country:US
Mailing Address - Phone:203-753-1419
Mailing Address - Fax:203-755-5336
Practice Address - Street 1:417 HIGHLAND AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708
Practice Address - Country:US
Practice Address - Phone:203-753-1419
Practice Address - Fax:203-755-5336
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT69691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice