Provider Demographics
NPI:1629529987
Name:SOUCY, CHRISTINE
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:SOUCY
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 1:49 LESLIE ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR LOCKS
Mailing Address - State:CT
Mailing Address - Zip Code:06096-1116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3372
Practice Address - Country:US
Practice Address - Phone:860-347-6971
Practice Address - Fax:860-638-6601
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4044124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist