Provider Demographics
NPI:1740240795
Name:MELLO, THERESA E (RDH)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:E
Last Name:MELLO
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 1:94 CONNECTICUT BLVD
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108
Mailing Address - Country:US
Mailing Address - Phone:860-528-1359
Mailing Address - Fax:860-291-8990
Practice Address - Street 1:94 CONNECTICUT BLVD
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108
Practice Address - Country:US
Practice Address - Phone:860-528-1359
Practice Address - Fax:860-291-8990
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005464124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist