Provider Demographics
NPI:1093703225
Name:KIERNAN, LANA THIBODEAU (RDH)
Entity Type:Individual
Prefix:MRS
First Name:LANA
Middle Name:THIBODEAU
Last Name:KIERNAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-2541
Mailing Address - Country:US
Mailing Address - Phone:860-365-0821
Mailing Address - Fax:
Practice Address - Street 1:397 NEW BRITAIN AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3833
Practice Address - Country:US
Practice Address - Phone:860-247-1021
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004491124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist