Healthcare Provider Details

I. General information

NPI: 1477851723
Provider Name (Legal Business Name): MALLETT'S BAY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 03/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 BLAKELY RD SUITE 104
COLCHESTER VT
05446-4008
US

IV. Provider business mailing address

97 BLAKELY RD SUITE 104
COLCHESTER VT
05446-4008
US

V. Phone/Fax

Practice location:
  • Phone: 802-862-8266
  • Fax: 802-862-6416
Mailing address:
  • Phone: 802-862-8266
  • Fax: 802-862-6416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number016-0002281
License Number StateVT

VIII. Authorized Official

Name: DR. DENHAM B. CRAFTON II
Title or Position: CEO
Credential: D.M.D.
Phone: 802-862-8266