Basic Information
Provider Information
NPI: 1336696947
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: URIBE
FirstName: WENDY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 128 WATER ST APT# 708
Address2:  
City: LEOMINSTER
State: MA
PostalCode: 014533252
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 128 WATER ST
Address2: APT# 708
City: LEOMINSTER
State: MA
PostalCode: 014533288
CountryCode: US
TelephoneNumber: 9788470110
FaxNumber: 9788788152
Other Information
ProviderEnumerationDate: 09/01/2016
LastUpdateDate: 09/01/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
124Q00000XDH89173MAY Dental ProvidersDental Hygienist 

No ID Information.


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