Basic Information
| Provider Information | |||||||||
| NPI: | 1972911840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAIDANS | ||||||||
| FirstName: | RUSLANS | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 MANSFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062262018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604507471 | ||||||||
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| Practice Location | |||||||||
| Address1: | 202 POMFRET ST | ||||||||
| Address2: | |||||||||
| City: | PUTNAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062601833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609637917 | ||||||||
| FaxNumber: | 8609630018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2014 | ||||||||
| LastUpdateDate: | 10/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 0401414459 | VA | N | Dental Providers | Dentist | 122300000X | 11721 | CT | Y | Dental Providers | Dentist |
No ID Information.