Provider Demographics
NPI:1053460907
Name:THE DENTAL CENTER AT COMMUNITY HEALTH CENTER OF BURLINGTON
Entity Type:Organization
Organization Name:THE DENTAL CENTER AT COMMUNITY HEALTH CENTER OF BURLINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-864-6309
Mailing Address - Street 1:617 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1601
Mailing Address - Country:US
Mailing Address - Phone:802-864-6309
Mailing Address - Fax:802-860-4324
Practice Address - Street 1:617 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1601
Practice Address - Country:US
Practice Address - Phone:802-864-6309
Practice Address - Fax:802-860-4324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0001692Medicaid