Provider Demographics
NPI:1255865200
Name:FERNANDES, CECILIA MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:MARIE
Last Name:FERNANDES
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 1:400 COLUMBUS AVE
Mailing Address - Street 2:CREDENTIALING SPECIALIST
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1233
Mailing Address - Country:US
Mailing Address - Phone:203-503-3174
Mailing Address - Fax:203-503-3174
Practice Address - Street 1:30 ELIZABETH ST STE 2
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1802
Practice Address - Country:US
Practice Address - Phone:203-736-5460
Practice Address - Fax:203-736-5462
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8467124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235900Medicaid