Healthcare Provider Details

I. General information

NPI: 1356633895
Provider Name (Legal Business Name): H
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 SOUTH WINDSOR ST
SOUTH ROYALTON VT
05068-0119
US

IV. Provider business mailing address

PO BOX 119
SOUTH ROYALTON VT
05068-0119
US

V. Phone/Fax

Practice location:
  • Phone: 802-889-3310
  • Fax: 802-763-2190
Mailing address:
  • Phone: 802-889-3310
  • Fax: 802-763-2190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number659
License Number StateVT

VIII. Authorized Official

Name: SUSAN HULL
Title or Position: CLINIC COORDINATOR
Credential:
Phone: 802-889-3310