Healthcare Provider Details

I. General information

NPI: 1063786374
Provider Name (Legal Business Name): WILLISTON ROAD FAMILY DENTAL , PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2012
Last Update Date: 03/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 WILLISTON RD
SOUTH BURLINGTON VT
05403-6469
US

IV. Provider business mailing address

1340 WILLISTON RD
SOUTH BURLINGTON VT
05403-6469
US

V. Phone/Fax

Practice location:
  • Phone: 802-863-0505
  • Fax:
Mailing address:
  • Phone: 802-863-0505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number0160002103
License Number StateVT

VIII. Authorized Official

Name: DAN MELO
Title or Position: OWNER/DENTIST
Credential: DMD
Phone: 802-863-0505