Provider Demographics
NPI:1720473267
Name:BARTLEY, KADEEM
Entity type:Individual
Prefix:
First Name:KADEEM
Middle Name:
Last Name:BARTLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:697 POQUONOCK AVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-2249
Mailing Address - Country:US
Mailing Address - Phone:860-219-0933
Mailing Address - Fax:860-219-1482
Practice Address - Street 1:697 POQUONOCK AVE
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-2249
Practice Address - Country:US
Practice Address - Phone:860-219-0933
Practice Address - Fax:860-219-1482
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059451-1122300000X, 1223G0001X
390200000X
CT124431223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program