Provider Demographics
NPI:1417417684
Name:TAGGART, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:TAGGART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 BAYBERRY CIR UNIT 102
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5509
Mailing Address - Country:US
Mailing Address - Phone:336-508-8652
Mailing Address - Fax:
Practice Address - Street 1:25 BISHOP AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7871
Practice Address - Country:US
Practice Address - Phone:802-878-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT016.01339391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program