Healthcare Provider Details

I. General information

NPI: 1619775822
Provider Name (Legal Business Name): LAURA NATALIA MARIN RUIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 06/21/2026
Certification Date: 06/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-0002
US

IV. Provider business mailing address

1 PHEASANT WAY
PITTSFIELD MA
01201-9123
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-2000
  • Fax:
Mailing address:
  • Phone: 904-450-0155
  • Fax: 904-450-0155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number84833
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDL100638
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: