Provider Demographics
NPI:1356633895
Name:H
Entity Type:Organization
Organization Name:H
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-889-3310
Mailing Address - Street 1:PO BOX 119
Mailing Address - Street 2:
Mailing Address - City:SOUTH ROYALTON
Mailing Address - State:VT
Mailing Address - Zip Code:05068-0119
Mailing Address - Country:US
Mailing Address - Phone:802-889-3310
Mailing Address - Fax:802-763-2190
Practice Address - Street 1:79 SOUTH WINDSOR ST
Practice Address - Street 2:
Practice Address - City:SOUTH ROYALTON
Practice Address - State:VT
Practice Address - Zip Code:05068-0119
Practice Address - Country:US
Practice Address - Phone:802-889-3310
Practice Address - Fax:802-763-2190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT6591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1016989Medicaid