Provider Demographics
NPI:1043434111
Name:NAWOTKA, EDWARD E (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:E
Last Name:NAWOTKA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 DORSET ST
Mailing Address - Street 2:SUITE 260
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6256
Mailing Address - Country:US
Mailing Address - Phone:802-863-5335
Mailing Address - Fax:802-863-9087
Practice Address - Street 1:150 DORSET ST
Practice Address - Street 2:SUITE 260
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6256
Practice Address - Country:US
Practice Address - Phone:802-863-5335
Practice Address - Fax:802-863-9087
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT10501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1003295Medicaid
VT745217OtherUNITED CONCORDIA PROVIDER
VT919-18741OtherBCBS PROVIDER NUMBER