Provider Demographics
NPI:1871660191
Name:SCIMONELLI, RICHARD M (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:SCIMONELLI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MERIDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-3227
Mailing Address - Country:US
Mailing Address - Phone:860-628-9994
Mailing Address - Fax:860-276-1963
Practice Address - Street 1:17 MERIDEN AVE
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-3227
Practice Address - Country:US
Practice Address - Phone:860-628-9994
Practice Address - Fax:860-276-1963
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT65751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice