Provider Demographics
NPI:1831350719
Name:STASULIS, JESSIE RICHTER (DMD)
Entity type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:RICHTER
Last Name:STASULIS
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 1:14 MAPLE STREET
Mailing Address - Street 2:
Mailing Address - City:TERRYVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06786-5220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14 MAPLE ST
Practice Address - Street 2:
Practice Address - City:TERRYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06786-5220
Practice Address - Country:US
Practice Address - Phone:860-583-3582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0098921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice