=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497182091
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIANA DEDEUS HAUGHEY DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2013
-----------------------------------------------------
Last Update Date | 09/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 HAWTHORNE DR
-----------------------------------------------------
City | SOUTHAMPTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01073-9473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-839-3413
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 HAWTHORNE DR
-----------------------------------------------------
City | SOUTHAMPTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01073-9473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-839-3413
-----------------------------------------------------
Fax | 406-839-3413
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 2901020553
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DN1856958
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------