Healthcare Provider Details

I. General information

NPI: 1932245362
Provider Name (Legal Business Name): VERMONT DENTAL MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 TIMBER LN
SOUTH BURLINGTON VT
05403-7204
US

IV. Provider business mailing address

40A TIMBER LN
SOUTH BURLINGTON VT
05403-7204
US

V. Phone/Fax

Practice location:
  • Phone: 802-862-7185
  • Fax: 802-658-8036
Mailing address:
  • Phone: 802-862-7185
  • Fax: 802-658-8036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number016-0000615
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: REIMY EVANGELISTA DE LEON
Title or Position: OWNER
Credential: DDS, CAGS, MS
Phone: 781-385-0484