Provider Demographics
NPI:1013319318
Name:ALBAN, BLANCA
Entity Type:Individual
Prefix:
First Name:BLANCA
Middle Name:
Last Name:ALBAN
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 1:125 MARSDEN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01109-1616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:470 MAPLE AVE
Practice Address - Street 2:MD FOX SCHOOL DENTAL CLINIC
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114-1215
Practice Address - Country:US
Practice Address - Phone:860-695-7735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003178124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist