Healthcare Provider Details

I. General information

NPI: 1942596317
Provider Name (Legal Business Name): ROSE-MARY JANE DYKAS L.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 BERLIN RD
CROMWELL CT
06416-1021
US

IV. Provider business mailing address

161 BERLIN RD
CROMWELL CT
06416-1021
US

V. Phone/Fax

Practice location:
  • Phone: 860-519-6228
  • Fax:
Mailing address:
  • Phone: 860-519-6228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number001658
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: