Provider Demographics
NPI:1477971257
Name:UDELSON, GRIFFIN B (DMD)
Entity type:Individual
Prefix:DR
First Name:GRIFFIN
Middle Name:B
Last Name:UDELSON
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 1:44 DALE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3676
Mailing Address - Country:US
Mailing Address - Phone:860-677-6405
Mailing Address - Fax:860-677-1189
Practice Address - Street 1:44 DALE RD STE 2
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3676
Practice Address - Country:US
Practice Address - Phone:860-677-6405
Practice Address - Fax:860-677-1189
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856847122300000X
390200000X
CT12712122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program