Healthcare Provider Details

I. General information

NPI: 1104465657
Provider Name (Legal Business Name): VT CENTER FOR DENTAL IMPLANTS AND MAXILLOFACIAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 S MAIN ST STE 1
STOWE VT
05672-5275
US

IV. Provider business mailing address

792 COLLEGE PKWY STE 307
COLCHESTER VT
05446-3052
US

V. Phone/Fax

Practice location:
  • Phone: 802-253-2761
  • Fax: 802-655-9366
Mailing address:
  • Phone: 802-655-5090
  • Fax: 800-524-4660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MRS. KAREN DESLAURIERS
Title or Position: BILLING MANAGER
Credential:
Phone: 802-655-5090