Provider Demographics
NPI:1427226380
Name:WILLARD STREET FAMILY DENTAL
Entity Type:Organization
Organization Name:WILLARD STREET FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:DESANCTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-868-4792
Mailing Address - Street 1:27 N WILLARD ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-3312
Mailing Address - Country:US
Mailing Address - Phone:802-862-8625
Mailing Address - Fax:
Practice Address - Street 1:27 N WILLARD ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-3312
Practice Address - Country:US
Practice Address - Phone:802-862-8625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0160002122122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty