Provider Demographics
NPI:1548502438
Name:KIMMEL, ELLIOT HAROLD (DDS,MS)
Entity type:Individual
Prefix:
First Name:ELLIOT
Middle Name:HAROLD
Last Name:KIMMEL
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-5973
Mailing Address - Country:US
Mailing Address - Phone:860-447-1714
Mailing Address - Fax:
Practice Address - Street 1:27 BROAD ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-5973
Practice Address - Country:US
Practice Address - Phone:860-447-1714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5842CT1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice