Provider Demographics
NPI:1275733354
Name:WATERBURY FAMILY DENTISTRY, PLC
Entity Type:Organization
Organization Name:WATERBURY FAMILY DENTISTRY, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:802-244-6366
Mailing Address - Street 1:77 S. MAIN ST.
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WATERBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05676
Mailing Address - Country:US
Mailing Address - Phone:802-244-6366
Mailing Address - Fax:802-244-8514
Practice Address - Street 1:77 S. MAIN ST.
Practice Address - Street 2:SUITE 3
Practice Address - City:WATERBURY
Practice Address - State:VT
Practice Address - Zip Code:05676
Practice Address - Country:US
Practice Address - Phone:802-244-6366
Practice Address - Fax:802-244-8514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0160001187122300000X
VT20311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1004239Medicaid