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NPI Code Detail

MEDICARE: GWENDOLYN BASILICA RDH

MEDICARE: GWENDOLYN BASILICA RDH
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1124Q00000XDental Hygienist002820CT

General Provider Information

NPI Number : 1588652697
Entity Type Code : Individual
Provider Name (Legal Business Name) : GWENDOLYN BASILICA RDH
Provider Business Mailing Address
First Line : 54 GARDNER AVE
Second Line :
City : NEW LONDON
State : CT
Zip : 06320-4313
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1 SHAWS CV
Second Line :
City : NEW LONDON
State : CT
Zip : 06320-4902
Country : US
Telephone Number : 860-444-0498
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/12/2005
Last Update Date : 07/08/2007

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Directions to “ GWENDOLYN BASILICA RDH” Practice Location

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