Healthcare Provider Details

I. General information

NPI: 1093703225
Provider Name (Legal Business Name): LANA THIBODEAU KIERNAN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

397 NEW BRITAIN AVE
HARTFORD CT
06106-3833
US

IV. Provider business mailing address

51 RIVER RD
COLCHESTER CT
06415-2541
US

V. Phone/Fax

Practice location:
  • Phone: 860-247-1021
  • Fax:
Mailing address:
  • Phone: 860-365-0821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number004491
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: