Provider Demographics
NPI:1194190561
Name:PASTORE, LEEANN
Entity Type:Individual
Prefix:
First Name:LEEANN
Middle Name:
Last Name:PASTORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 N FOREST CIR
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-7939
Mailing Address - Country:US
Mailing Address - Phone:203-314-8172
Mailing Address - Fax:
Practice Address - Street 1:26 N FOREST CIR
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-7939
Practice Address - Country:US
Practice Address - Phone:203-314-8172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006242124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT01352-6542Medicaid