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General NPI Number Information
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NPI Number | 1598433971
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Entity Type | Organization
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Legal Business Name | NUTMEG ORTHODONTICS, LLC
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Dates
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Enumeration Date | 09/01/2021
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Last Update Date | 09/01/2021
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Provider Practice Location Address
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Address Line | 62 BLOOMFIELD AVE
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City | WINDSOR
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State | CT
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Zip | 06095-2808
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Country | US
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Telephone | 860-688-6030
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Fax |
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Provider Business Mailing Address
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Address Line | 62 BLOOMFIELD AVE
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City | WINDSOR
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State | CT
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Zip | 06095-2808
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Country | US
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Telephone | 860-688-6030
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. ANU NELLISSERY
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Credential | DMD, MS
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Telephone | 860-688-6030
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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