Provider Demographics
NPI:1134473218
Name:VERMONT TECHNICAL COLLEGE DEPARTMENT OF DENTA
Entity Type:Organization
Organization Name:VERMONT TECHNICAL COLLEGE DEPARTMENT OF DENTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-879-5643
Mailing Address - Street 1:301 LAWRENCE PLACE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495
Mailing Address - Country:US
Mailing Address - Phone:802-879-5643
Mailing Address - Fax:802-879-2317
Practice Address - Street 1:301 LAWRENCE PLACE
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495
Practice Address - Country:US
Practice Address - Phone:802-879-5643
Practice Address - Fax:802-879-2317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty