Healthcare Provider Details

I. General information

NPI: 1457638892
Provider Name (Legal Business Name): UPPER VALLEY ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 02/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 BILLINGS FARM RD SUITE 6A
WHITE RIVER JUNCTION VT
05001-5400
US

IV. Provider business mailing address

205 BILLINGS FARM RD
WHITE RIVER JUNCTION VT
05001-5400
US

V. Phone/Fax

Practice location:
  • Phone: 802-295-7522
  • Fax: 802-296-2012
Mailing address:
  • Phone: 802-295-7522
  • Fax: 802-296-2012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number016.0093923
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number49567
License Number StateVT

VIII. Authorized Official

Name: DR. BROOKE BLICHER
Title or Position: OWNER
Credential: DMD
Phone: 802-295-7522