Healthcare Provider Details

I. General information

NPI: 1215893243
Provider Name (Legal Business Name): RIVERBEND ORAL AND MAXILLOFACIAL SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2026
Last Update Date: 01/03/2026
Certification Date: 01/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1066 GRANBY RD
CHICOPEE MA
01020-1539
US

IV. Provider business mailing address

1066 GRANBY RD
CHICOPEE MA
01020-1539
US

V. Phone/Fax

Practice location:
  • Phone: 413-534-4400
  • Fax:
Mailing address:
  • Phone: 413-534-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DR. ANJU NELLISSERY
Title or Position: PRESIDENT
Credential: DMD, MD
Phone: 860-335-0168