Provider Demographics
NPI:1477843944
Name:NIST, JUDITH ANN (RDH)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:NIST
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:ANN
Other - Last Name:SINANIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:888 WORCESTER ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-3744
Mailing Address - Country:US
Mailing Address - Phone:617-964-6681
Mailing Address - Fax:339-686-2561
Practice Address - Street 1:85 BARNES RD
Practice Address - Street 2:SUITE 207
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-1832
Practice Address - Country:US
Practice Address - Phone:203-678-1201
Practice Address - Fax:203-678-1209
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002141124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist