=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154065514
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MITRA MARVASTI-SITTERLY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2022
-----------------------------------------------------
Last Update Date | 06/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 381 HOPMEADOW ST STE 202
-----------------------------------------------------
City | WEATOGUE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06089-9697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-658-7548
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 181 PARTRIDGE LNDG
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-2849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-692-8127
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN1859415
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 13636
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DN1859415
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 13758
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 13636
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------