Healthcare Provider Details

I. General information

NPI: 1710951009
Provider Name (Legal Business Name): LAURA A BENEDETTO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 HEBRON AVE SUITE 107
GLASTONBURY CT
06033-5007
US

IV. Provider business mailing address

628 HEBRON AVE SUITE 107
GLASTONBURY CT
06033-5007
US

V. Phone/Fax

Practice location:
  • Phone: 860-657-3376
  • Fax: 860-633-6040
Mailing address:
  • Phone: 860-657-3376
  • Fax: 860-633-6040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number000275
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: