Provider Demographics
NPI:1295749562
Name:BUCALO, LYNNE BLOOM (DDS)
Entity type:Individual
Prefix:DR
First Name:LYNNE
Middle Name:BLOOM
Last Name:BUCALO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 HAZARD AVENUE
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082
Mailing Address - Country:US
Mailing Address - Phone:860-749-0533
Mailing Address - Fax:860-749-1212
Practice Address - Street 1:421 HAZARD AVENUE
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082
Practice Address - Country:US
Practice Address - Phone:860-749-0533
Practice Address - Fax:860-749-1212
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT40791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice