Provider Demographics
NPI:1811487283
Name:VELASTEGUI, PABLO ENRIQUE (DMD)
Entity type:Individual
Prefix:
First Name:PABLO
Middle Name:ENRIQUE
Last Name:VELASTEGUI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 SHADOW LN UNIT A1
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-1677
Mailing Address - Country:US
Mailing Address - Phone:347-256-6177
Mailing Address - Fax:
Practice Address - Street 1:41 TAYLOR ST STE 4
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-1332
Practice Address - Country:US
Practice Address - Phone:413-781-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18579031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice