Provider Demographics
NPI:1376830661
Name:VANGUARD DENTAL LLC
Entity Type:Organization
Organization Name:VANGUARD DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YOGITA
Authorized Official - Middle Name:S
Authorized Official - Last Name:KANORWALLA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-221-5655
Mailing Address - Street 1:15 HORSESHOE LN
Mailing Address - Street 2:
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095-1315
Mailing Address - Country:US
Mailing Address - Phone:508-221-5655
Mailing Address - Fax:
Practice Address - Street 1:1730 BOSTON RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01129-1175
Practice Address - Country:US
Practice Address - Phone:413-543-2575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN206521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty