Provider Demographics
NPI:1386866366
Name:MATHERLY, JITKA H (DDS)
Entity Type:Individual
Prefix:
First Name:JITKA
Middle Name:H
Last Name:MATHERLY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05661-0749
Mailing Address - Country:US
Mailing Address - Phone:802-888-7585
Mailing Address - Fax:802-851-8313
Practice Address - Street 1:66 MORRISVILLE PLZ
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:VT
Practice Address - Zip Code:05661-4482
Practice Address - Country:US
Practice Address - Phone:802-888-7585
Practice Address - Fax:802-851-8313
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD132681223G0001X
VT0160105895122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice