Healthcare Provider Details

I. General information

NPI: 1669511192
Provider Name (Legal Business Name): DR. RENAY IVENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 FIDDLERS GRN
WAITSFIELD VT
05673-6007
US

IV. Provider business mailing address

192 BUCK HOLLOW RD
FAIRFAX VT
05454-9661
US

V. Phone/Fax

Practice location:
  • Phone: 802-496-2524
  • Fax:
Mailing address:
  • Phone: 802-849-6841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number016-0002223
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: