Healthcare Provider Details

I. General information

NPI: 1700923489
Provider Name (Legal Business Name): AUDRA ELAINE HAYNES R.D.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3703 10TH AVE
NEW YORK NY
10034-1860
US

IV. Provider business mailing address

429 FRANKLIN AVE
BROOKLYN NY
11238-2014
US

V. Phone/Fax

Practice location:
  • Phone: 212-567-6066
  • Fax:
Mailing address:
  • Phone: 718-638-8652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number018462-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: