Healthcare Provider Details

I. General information

NPI: 1700800471
Provider Name (Legal Business Name): VERMONT ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 TIMBER LANE
SOUTH BRIGHTON VT
05403-7282
US

IV. Provider business mailing address

44 TIMBER LANE
SOUTH BRIGHTON VT
05403-7282
US

V. Phone/Fax

Practice location:
  • Phone: 802-860-6725
  • Fax: 802-864-1511
Mailing address:
  • Phone: 802-860-6725
  • Fax: 802-864-1511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: THOMAS WILLIAM CONNOLLY
Title or Position: PARTNER
Credential: DMD
Phone: 802-860-6725