Provider Demographics
NPI:1346408184
Name:WITTER, MICHELLE A (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:A
Last Name:WITTER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 TILDEN AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-2507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 ASYLUM AVE
Practice Address - Street 2:SUITE 3200
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1770
Practice Address - Country:US
Practice Address - Phone:860-714-4529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0546481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004011136Medicaid
NY03203885Medicaid