Healthcare Provider Details

I. General information

NPI: 1568794295
Provider Name (Legal Business Name): WEST RIVER FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2010
Last Update Date: 02/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 GRAFTON RD
TOWNSHEND VT
05353-0262
US

IV. Provider business mailing address

74 GRAFTON ROAD PO BOX 262
TOWNSHEND VT
05353
US

V. Phone/Fax

Practice location:
  • Phone: 802-365-4313
  • Fax:
Mailing address:
  • Phone: 802-365-4313
  • Fax: 802-365-4313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0160002226
License Number StateVT

VIII. Authorized Official

Name: DR. JARED VERNON REDISKE
Title or Position: DENTIST
Credential: D.D.S.
Phone: 802-365-4313