Provider Demographics
NPI:1568688364
Name:MATTESEN, KELLY (RDH)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:MATTESEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06480-1526
Mailing Address - Country:US
Mailing Address - Phone:860-342-4088
Mailing Address - Fax:
Practice Address - Street 1:84 GLASTONBURY BLVD
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4468
Practice Address - Country:US
Practice Address - Phone:860-657-5522
Practice Address - Fax:860-657-5558
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004535124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist