Basic Information
| Provider Information | |||||||||
| NPI: | 1528536745 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OJEDA | ||||||||
| FirstName: | VIVIANA | ||||||||
| MiddleName: | ANGELINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 GOLD ST | ||||||||
| Address2: | |||||||||
| City: | GREENWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068305922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034466627 | ||||||||
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| Practice Location | |||||||||
| Address1: | 428 COLUMBUS AVENUE | ||||||||
| Address2: | COLUMBUS DENTAL | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033040 | ||||||||
| FaxNumber: | 2035033187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2018 | ||||||||
| LastUpdateDate: | 11/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 12308 | CT | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 004235893 | 05 | CT | MEDICAID |