Healthcare Provider Details

I. General information

NPI: 1497182091
Provider Name (Legal Business Name): MARIANA DEDEUS HAUGHEY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 09/29/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 HAWTHORNE DR
SOUTHAMPTON MA
01073-9473
US

IV. Provider business mailing address

5 HAWTHORNE DR
SOUTHAMPTON MA
01073-9473
US

V. Phone/Fax

Practice location:
  • Phone: 406-839-3413
  • Fax:
Mailing address:
  • Phone: 406-839-3413
  • Fax: 406-839-3413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901020553
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN1856958
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: