Provider Demographics
NPI:1629176201
Name:TILLMAN, CAROLYN FETZER
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:FETZER
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:CAROLYN
Other - Middle Name:JEANNE
Other - Last Name:FETZER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:35 PLEASANT STREET
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450
Mailing Address - Country:US
Mailing Address - Phone:203-237-6400
Mailing Address - Fax:203-237-9769
Practice Address - Street 1:35 PLEASANT STREET
Practice Address - Street 2:SUITE 2B
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450
Practice Address - Country:US
Practice Address - Phone:203-237-6400
Practice Address - Fax:203-237-9769
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5279122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist