Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 006695 | CT |
NPI | 1013121417 |
---|---|
Provider Name | Mr. Hector J Maldonado |
First Address | Newington, CT 06111-3603 |
Second Address | Hartford, CT 06105-1770 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
006695 | DENTAL HYGIENIST LICENSE (01) | CT |