Individual
DESIREE NICOLE OUTLAW
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DDS
Contact information
Practice address
94 CONNECTICUT BLVD, EAST HARTFORD, CT 06108-3013
(860) 610-6348
Mailing address
22 LIBERTY SQ APT 381, BLOOMFIELD, CT 06002-5407
(301) 325-6412
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
12817
CT
1223G0001X
General Practice Dentistry
060129
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12817
DENTAL LICENSE
CT
Enumeration date
09/26/2018
Last updated
07/23/2020
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