Healthcare Provider Details

I. General information

NPI: 1437980778
Provider Name (Legal Business Name): ANDREW GEORGE VULTAGGIO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 08/09/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 THOREAU ST
CONCORD MA
01742-2443
US

IV. Provider business mailing address

115 THOREAU ST
CONCORD MA
01742-2443
US

V. Phone/Fax

Practice location:
  • Phone: 978-371-2792
  • Fax:
Mailing address:
  • Phone: 978-371-2792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1000412
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: