Healthcare Provider Details

I. General information

NPI: 1023093606
Provider Name (Legal Business Name): MURRAY DINER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 06/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 MAIN ST
RICHFORD VT
05476-1151
US

IV. Provider business mailing address

212 PROUTY DRIVE SUITE 1
NEWPORT VT
05855
US

V. Phone/Fax

Practice location:
  • Phone: 802-848-3829
  • Fax: 802-848-3849
Mailing address:
  • Phone: 802-334-6965
  • Fax: 802-334-6606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number016.0002044
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: