Provider Demographics
NPI:1417408717
Name:TACONIC DENTAL ARTS PC
Entity Type:Organization
Organization Name:TACONIC DENTAL ARTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:JUSTIN
Authorized Official - Last Name:CARMACK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:802-773-1020
Mailing Address - Street 1:163 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4500
Mailing Address - Country:US
Mailing Address - Phone:802-442-9500
Mailing Address - Fax:
Practice Address - Street 1:163 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4500
Practice Address - Country:US
Practice Address - Phone:802-442-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT01600733651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty