Provider Demographics
NPI:1235572918
Name:NEW ENGLAND ORAL SURGERY PC
Entity Type:Organization
Organization Name:NEW ENGLAND ORAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MELVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-622-0678
Mailing Address - Street 1:14 N MAIN ST
Mailing Address - Street 2:SUITE 4001
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-4197
Mailing Address - Country:US
Mailing Address - Phone:802-622-0323
Mailing Address - Fax:
Practice Address - Street 1:14 N MAIN ST
Practice Address - Street 2:SUITE 4001
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-4197
Practice Address - Country:US
Practice Address - Phone:802-622-0323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-11
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016.00020591223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0034668OtherMEDICARE PTAN
VT1022121Medicaid