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General NPI Number Information
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NPI Number | 1780886036
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Entity Type | Organization
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Legal Business Name | GREEN MOUNTAIN ORAL SURGERY LLC
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Dates
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Enumeration Date | 05/31/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 66 N MAIN ST
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City | RUTLAND
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State | VT
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Zip | 05701-3249
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Country | US
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Telephone | 802-775-9700
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Fax | 802-775-3237
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Provider Business Mailing Address
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Address Line | 66 N MAIN ST
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City | RUTLAND
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State | VT
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Zip | 05701-3249
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Country | US
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Telephone | 802-775-9700
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Fax | 802-775-3237
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Authorized Official
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Title or Position | ORAL SURGEON
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Name | DR. SHERILYNN STOFKA
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Credential | D.D.S.
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Telephone | 802-775-9700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 0160002076
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License Number State | VT
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