Healthcare Provider Details

I. General information

NPI: 1619254364
Provider Name (Legal Business Name): SCOTT KESSELMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2011
Last Update Date: 11/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1171 E PUTNAM AVE BUILDING 2, SUITE C
RIVERSIDE CT
06878-1426
US

IV. Provider business mailing address

1171 E PUTNAM AVE BUILDING 2, SUITE C
RIVERSIDE CT
06878-1426
US

V. Phone/Fax

Practice location:
  • Phone: 203-698-0045
  • Fax:
Mailing address:
  • Phone: 203-698-0045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number008463
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: