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General NPI Number Information
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NPI Number | 1851404271
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Entity Type | Organization
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Legal Business Name | MIDDLEBURY DENTAL GROUP
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Dates
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Enumeration Date | 08/17/2006
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Last Update Date | 01/05/2010
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Provider Practice Location Address
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Address Line | 1330 EXCHANGE ST
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City | MIDDLEBURY
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State | VT
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Zip | 05753-4425
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Country | US
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Telephone | 802-388-3553
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Fax | 802-388-7377
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Provider Business Mailing Address
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Address Line | 1330 EXCHANGE ST
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City | MIDDLEBURY
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State | VT
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Zip | 05753-4425
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Country | US
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Telephone | 802-388-3553
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Fax | 802-388-7377
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | KIM RODERICK MONTGOMERY
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Credential | DMD
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Telephone | 802-388-3553
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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