Provider Demographics
NPI:1093904161
Name:HULTGREN, MARY ANN (RDH)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:
Last Name:HULTGREN
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 1:121 LEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06471-1816
Mailing Address - Country:US
Mailing Address - Phone:203-481-8658
Mailing Address - Fax:
Practice Address - Street 1:419 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-1918
Practice Address - Country:US
Practice Address - Phone:203-624-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006210124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist