MEDICARE: CANDID VERMONT, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1003423112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANDID VERMONT, PLLC

Provider Business Mailing Address
First Line	:	145 PINE HAVEN SHORES RD STE 1000O
Second Line	:
City	:	SHELBURNE
State	:	VT
Zip	:	05482-7812
Country	:	US
Telephone Number	:	860-481-7631
Fax Number	:

Provider Business Practice Location Address
First Line	:	145 PINE HAVEN SHORES RD STE 1000O
Second Line	:
City	:	SHELBURNE
State	:	VT
Zip	:	05482-7812
Country	:	US
Telephone Number	:	860-481-7631
Fax Number	:

Authorized Official
Title or Position	:	DDS
Name	:	RICHARD D'AVANZO
Credential	:
Telephone Number	:	860-481-7631

Provider Enumeration Date	:	09/23/2020
Last Update Date	:	09/23/2020

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