Healthcare Provider Details

I. General information

NPI: 1821465170
Provider Name (Legal Business Name): JOSSEELAINE DIAZ RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2015
Last Update Date: 08/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 PHOENIX AVE
WATERBURY CT
06702-1418
US

IV. Provider business mailing address

1302 S MAIN ST
WATERBURY CT
06706-1748
US

V. Phone/Fax

Practice location:
  • Phone: 203-756-8021
  • Fax: 203-597-8860
Mailing address:
  • Phone: 203-756-8021
  • Fax: 203-596-9038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number008430
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: