Healthcare Provider Details

I. General information

NPI: 1730691163
Provider Name (Legal Business Name): TAMMY VALADAKIS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2017
Last Update Date: 10/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

294 S MAIN ST
NORTHFIELD VT
05663-5783
US

IV. Provider business mailing address

PO BOX 1604
WAITSFIELD VT
05673-1604
US

V. Phone/Fax

Practice location:
  • Phone: 802-485-5100
  • Fax:
Mailing address:
  • Phone: 802-917-1113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number1563
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: