Provider Demographics
NPI:1063604924
Name:BLANCHARD, SUSAN (RDH, RN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BLANCHARD
Suffix:
Gender:F
Credentials:RDH, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 MAIN ST
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2718
Mailing Address - Country:US
Mailing Address - Phone:860-347-6971
Mailing Address - Fax:860-638-6601
Practice Address - Street 1:141 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-1014
Practice Address - Country:US
Practice Address - Phone:203-969-0802
Practice Address - Fax:203-326-2990
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006543124Q00000X
CTE47045163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No163W00000XNursing Service ProvidersRegistered Nurse