Provider Demographics
NPI:1811605090
Name:AMATO, TRACEY LEE (RDH)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:LEE
Last Name:AMATO
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 1:330 WETHERSFIELD AVE OFC
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06114-1409
Mailing Address - Country:US
Mailing Address - Phone:606-958-8548
Mailing Address - Fax:
Practice Address - Street 1:330 WETHERSFIELD AVE OFC
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114-1409
Practice Address - Country:US
Practice Address - Phone:606-958-8548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005024124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT19090120OtherDR. DOUGLAS MACGILPIN