Healthcare Provider Details

I. General information

NPI: 1790872588
Provider Name (Legal Business Name): KEILA NORMAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 HEMPSTEAD ST
NEW LONDON CT
06320-6248
US

IV. Provider business mailing address

190 HEMPSTEAD ST
NEW LONDON CT
06320-6248
US

V. Phone/Fax

Practice location:
  • Phone: 860-443-2428
  • Fax: 800-583-0877
Mailing address:
  • Phone: 860-443-2428
  • Fax: 800-583-0877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number16339
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number10150
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: