Basic Information
| Provider Information | |||||||||
| NPI: | 1952384885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEIN | ||||||||
| FirstName: | VITALY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 471 BARNUM AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066082409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033336864 | ||||||||
| FaxNumber: | 2033320376 | ||||||||
| Practice Location | |||||||||
| Address1: | 982 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066081913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036963260 | ||||||||
| FaxNumber: | 2033320376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 005722 | CT | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 005722 | 01 | CT | STATE LICENSE | OTHER |