Provider Demographics
NPI:1174811160
Name:NODA-CLARK, ROSA (RDH)
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:
Last Name:NODA-CLARK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:ROSA
Other - Middle Name:
Other - Last Name:NODA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:1 CHELSEA LN
Mailing Address - Street 2:
Mailing Address - City:EAST GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06026-9634
Mailing Address - Country:US
Mailing Address - Phone:860-380-0830
Mailing Address - Fax:
Practice Address - Street 1:1 CHELSEA LN
Practice Address - Street 2:
Practice Address - City:EAST GRANBY
Practice Address - State:CT
Practice Address - Zip Code:06026
Practice Address - Country:US
Practice Address - Phone:860-380-0830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2018-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006043124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist