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General NPI Number Information
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NPI Number | 1912100256
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Entity Type | Organization
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Legal Business Name | MAPLE LEAF FAMILY DENTISTRY
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Dates
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Enumeration Date | 06/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 58 BRIGHAM STREET
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City | MORRISVILLE
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State | VT
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Zip | 05661
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Country | US
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Telephone | 802-888-5685
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 636
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City | MORRISVILLE
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State | VT
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Zip | 05661-0636
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Country | US
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Telephone | 802-888-5685
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MATTHEW S EBERT
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Credential | DMD
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Telephone | 802-888-5685
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 016-0002038
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License Number State | VT
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