Healthcare Provider Details

I. General information

NPI: 1780324400
Provider Name (Legal Business Name): ROSEMARY LOPEZ RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 COLUMBUS AVE
NEW HAVEN CT
06519-1233
US

IV. Provider business mailing address

15 MURRAY ST APT 1
ANSONIA CT
06401-2178
US

V. Phone/Fax

Practice location:
  • Phone: 203-503-3731
  • Fax:
Mailing address:
  • Phone: 646-409-9084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number028240
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number009300
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: