Healthcare Provider Details

I. General information

NPI: 1568688364
Provider Name (Legal Business Name): KELLY MATTESEN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 GLASTONBURY BLVD
GLASTONBURY CT
06033-4468
US

IV. Provider business mailing address

440 MAIN ST
PORTLAND CT
06480-1526
US

V. Phone/Fax

Practice location:
  • Phone: 860-657-5522
  • Fax: 860-657-5558
Mailing address:
  • Phone: 860-342-4088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number004535
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: