Provider Demographics
NPI:1760632327
Name:MANDELL, JAY S (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:S
Last Name:MANDELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 TOWN LINE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4352
Mailing Address - Country:US
Mailing Address - Phone:860-563-6500
Mailing Address - Fax:860-563-6501
Practice Address - Street 1:55 TOWN LINE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-4352
Practice Address - Country:US
Practice Address - Phone:860-563-6500
Practice Address - Fax:860-563-6501
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT50401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
5040OtherSTATE LICENSE