Healthcare Provider Details

I. General information

NPI: 1992784227
Provider Name (Legal Business Name): DIANE R. D'AMBROSIO R. D. H.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 MAIN ST
WILLIMANTIC CT
06226-1948
US

IV. Provider business mailing address

1315 MAIN ST
WILLIMANTIC CT
06226-1948
US

V. Phone/Fax

Practice location:
  • Phone: 860-450-7471
  • Fax: 860-423-4629
Mailing address:
  • Phone: 860-450-7471
  • Fax: 860-423-4629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number002598
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: