Healthcare Provider Details

I. General information

NPI: 1568635837
Provider Name (Legal Business Name): MARY COLLEEN ANDERSON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 10/16/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 PINE ST
BRISTOL VT
05443-1043
US

IV. Provider business mailing address

PO BOX 363
BETHEL VT
05032-0363
US

V. Phone/Fax

Practice location:
  • Phone: 802-453-3911
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1855175
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number016.0134179
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: