Provider Demographics
NPI:1215045554
Name:LISCIO, JOHN (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LISCIO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 HEINEBERG DR
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446
Mailing Address - Country:US
Mailing Address - Phone:802-658-4873
Mailing Address - Fax:802-863-5400
Practice Address - Street 1:369 HEINEBERG DR
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446
Practice Address - Country:US
Practice Address - Phone:802-658-4873
Practice Address - Fax:802-863-5400
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016-0000868122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0002459Medicaid
VT0002459Medicaid