Provider Demographics
NPI:1740209030
Name:PAULOSE, MAYA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MAYA
Middle Name:
Last Name:PAULOSE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 FLAHERTY RD
Mailing Address - Street 2:
Mailing Address - City:STORRS MANSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06268-2353
Mailing Address - Country:US
Mailing Address - Phone:860-429-0230
Mailing Address - Fax:860-429-6158
Practice Address - Street 1:72 FLAHERTY ROAD
Practice Address - Street 2:
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06268-2353
Practice Address - Country:US
Practice Address - Phone:860-429-0230
Practice Address - Fax:860-429-6158
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT79011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002079011Medicaid