Healthcare Provider Details

I. General information

NPI: 1588652697
Provider Name (Legal Business Name): GWENDOLYN BASILICA RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

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

1 SHAWS CV
NEW LONDON CT
06320-4902
US

IV. Provider business mailing address

54 GARDNER AVE
NEW LONDON CT
06320-4313
US

V. Phone/Fax

Practice location:
  • Phone: 860-444-0498
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number002820
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: