Healthcare Provider Details

I. General information

NPI: 1386866366
Provider Name (Legal Business Name): JITKA H. MATHERLY D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 MORRISVILLE PLZ
MORRISVILLE VT
05661-4482
US

IV. Provider business mailing address

PO BOX 749
MORRISVILLE VT
05661-0749
US

V. Phone/Fax

Practice location:
  • Phone: 802-888-7585
  • Fax: 802-851-8313
Mailing address:
  • Phone: 802-888-7585
  • Fax: 802-851-8313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0160105895
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13268
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: