Provider Demographics
NPI:1083850374
Name:JEDIDIAH L JANISSE DMD AND ASSOCIATES, LTD
Entity Type:Organization
Organization Name:JEDIDIAH L JANISSE DMD AND ASSOCIATES, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEDIDIAH
Authorized Official - Middle Name:L
Authorized Official - Last Name:JANISSE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:802-457-1903
Mailing Address - Street 1:217 MAXHAM MEADOW WAY # 10
Mailing Address - Street 2:SUITE 4C
Mailing Address - City:WOODSTOCK
Mailing Address - State:VT
Mailing Address - Zip Code:05091-1162
Mailing Address - Country:US
Mailing Address - Phone:802-457-1903
Mailing Address - Fax:802-457-3619
Practice Address - Street 1:217 MAXHAM MEADOW WAY # 10
Practice Address - Street 2:SUITE 4C
Practice Address - City:WOODSTOCK
Practice Address - State:VT
Practice Address - Zip Code:05091-1162
Practice Address - Country:US
Practice Address - Phone:802-457-1903
Practice Address - Fax:802-457-3619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016-0002247122300000X
261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No122300000XDental ProvidersDentistGroup - Single Specialty