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General NPI Number Information
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NPI Number | 1619443546
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Entity Type | Individual
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Provider Name | ADISA RATANASIRINTRAWOOT
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Gender | Female
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Dates
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Enumeration Date | 10/18/2018
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Last Update Date | 09/28/2021
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Provider Practice Location Address
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Address Line | 1775 WILLISTON RD
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City | SOUTH BURLINGTON
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State | VT
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Zip | 05403-6491
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Country | US
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Telephone | 802-863-5447
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Fax |
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Provider Business Mailing Address
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Address Line | 77 PINE ST APT 509
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City | BURLINGTON
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State | VT
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Zip | 05401-5945
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Country | US
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Telephone | 857-361-2255
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 016.0134058
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License Number State | VT
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