Healthcare Provider Details

I. General information

NPI: 1518964154
Provider Name (Legal Business Name): DOUGLAS EDWARD DENNETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 CARMICHAEL ST UNIT 204
ESSEX JCT VT
05452-3216
US

IV. Provider business mailing address

8 CARMICHAEL ST UNIT 204
ESSEX JCT VT
05452-3216
US

V. Phone/Fax

Practice location:
  • Phone: 802-872-9263
  • Fax: 802-872-8222
Mailing address:
  • Phone: 802-872-9263
  • Fax: 802-872-8222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0420007975
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0420007975
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: