=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710951009
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA A BENEDETTO D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2006
-----------------------------------------------------
Last Update Date | 07/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 628 HEBRON AVE SUITE 107
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-5007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-657-3376
-----------------------------------------------------
Fax | 860-633-6040
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 628 HEBRON AVE SUITE 107
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-5007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-657-3376
-----------------------------------------------------
Fax | 860-633-6040
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 000275
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------