Healthcare Provider Details

I. General information

NPI: 1528448172
Provider Name (Legal Business Name): ELICIA LUPOLI RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 MEADOW ST FL 3
NEW HAVEN CT
06519-1719
US

IV. Provider business mailing address

8 JEFFERSON ST
SEYMOUR CT
06483-2110
US

V. Phone/Fax

Practice location:
  • Phone: 475-220-1230
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number006598
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: