Healthcare Provider Details

I. General information

NPI: 1487769659
Provider Name (Legal Business Name): PAUL LEO DAVOREN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 12/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 TOWN AVE
PLAINFIELD VT
05667-0320
US

IV. Provider business mailing address

PO BOX 320
PLAINFIELD VT
05667-0320
US

V. Phone/Fax

Practice location:
  • Phone: 802-454-1057
  • Fax: 802-454-8339
Mailing address:
  • Phone: 802-454-1057
  • Fax: 802-454-8339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0160000796
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: