Basic Information
Provider Information
NPI: 1144630948
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GALLON
FirstName: LORI
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 43 CHENEY LN
Address2:  
City: NEWINGTON
State: CT
PostalCode: 061113112
CountryCode: US
TelephoneNumber: 8606674425
FaxNumber:  
Practice Location
Address1: 763 BURNSIDE AVE
Address2:  
City: EAST HARTFORD
State: CT
PostalCode: 061082791
CountryCode: US
TelephoneNumber: 8602919728
FaxNumber: 8602919728
Other Information
ProviderEnumerationDate: 05/01/2014
LastUpdateDate: 05/01/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
124Q00000X007380CTY Dental ProvidersDental Hygienist 

No ID Information.


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