=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003512690
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN ELLIOT GUIDO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2023
-----------------------------------------------------
Last Update Date | 12/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 CANAL ST
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06902-6094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-204-6888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35 BRECKENRIDGE AVE
-----------------------------------------------------
City | PORT CHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10573-2901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-960-8787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 14241
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 064051
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------