Healthcare Provider Details

I. General information

NPI: 1275912115
Provider Name (Legal Business Name): JEREMY MAC CLOVER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 VT ROUTE 7A
SHAFTSBURY VT
05262-9548
US

IV. Provider business mailing address

677 VT ROUTE 7A
SHAFTSBURY VT
05262-9548
US

V. Phone/Fax

Practice location:
  • Phone: 802-442-7300
  • Fax:
Mailing address:
  • Phone: 802-442-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number016.0111405
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number016.0111405
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: