Healthcare Provider Details

I. General information

NPI: 1235572918
Provider Name (Legal Business Name): NEW ENGLAND ORAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 N MAIN ST SUITE 4001
BARRE VT
05641-4197
US

IV. Provider business mailing address

14 N MAIN ST SUITE 4001
BARRE VT
05641-4197
US

V. Phone/Fax

Practice location:
  • Phone: 802-622-0323
  • Fax:
Mailing address:
  • Phone: 802-622-0323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number016.0002059
License Number StateVT

VIII. Authorized Official

Name: MS. PATRICIA MELVIN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 802-622-0678