Provider Demographics
NPI:1285858068
Name:MARY C SQUIRE DDS PC
Entity Type:Organization
Organization Name:MARY C SQUIRE DDS PC
Other - Org Name:MARY C SQUIRE DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:SQUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:802-366-9119
Mailing Address - Street 1:PO BOX 1724
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05255
Mailing Address - Country:US
Mailing Address - Phone:802-366-9119
Mailing Address - Fax:802-366-9099
Practice Address - Street 1:3429 RICHVILLE RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER CT
Practice Address - State:VT
Practice Address - Zip Code:05255
Practice Address - Country:US
Practice Address - Phone:802-366-9119
Practice Address - Fax:802-366-9099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1079122300000X
NY041234122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty