Healthcare Provider Details

I. General information

NPI: 1154958213
Provider Name (Legal Business Name): COLLIN KWASNIK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 PAINE TPKE N
BERLIN VT
05602-9157
US

IV. Provider business mailing address

1511 COX BROOK RD
NORTHFIELD VT
05663-6614
US

V. Phone/Fax

Practice location:
  • Phone: 802-229-0561
  • Fax:
Mailing address:
  • Phone: 802-272-4498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number016.0133962
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: