Provider Demographics
NPI:1265115240
Name:MORONTA, CARMEN
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:MORONTA
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 1:136 ARDMORE RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06461-2206
Mailing Address - Country:US
Mailing Address - Phone:646-416-2778
Mailing Address - Fax:
Practice Address - Street 1:111 WILBUR PECK CT
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-6323
Practice Address - Country:US
Practice Address - Phone:203-717-1760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031098124Q00000X
CT009297124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist