Healthcare Provider Details

I. General information

NPI: 1154534238
Provider Name (Legal Business Name): SALEM DENTISTRY P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 ELM ST
BENNINGTON VT
05201-2249
US

IV. Provider business mailing address

107 ELM ST
BENNINGTON VT
05201-2249
US

V. Phone/Fax

Practice location:
  • Phone: 802-447-7147
  • Fax:
Mailing address:
  • Phone: 802-447-7147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number016-0001238
License Number StateVT

VIII. Authorized Official

Name: DR. JUSTIN P. SALEM
Title or Position: DENTIST
Credential: D.D.S.
Phone: 802-447-7147