Healthcare Provider Details

I. General information

NPI: 1245404219
Provider Name (Legal Business Name): RICHARD DIOTALEVI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2008
Last Update Date: 04/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 TIMBER LN
BETHANY CT
06524-3332
US

IV. Provider business mailing address

24 TIMBER LN
BETHANY CT
06524-3332
US

V. Phone/Fax

Practice location:
  • Phone: 203-393-0265
  • Fax:
Mailing address:
  • Phone: 203-393-0265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number006208
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: