Provider Demographics
NPI:1477851723
Name:MALLETT'S BAY DENTISTRY
Entity Type:Organization
Organization Name:MALLETT'S BAY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DENHAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:CRAFTON
Authorized Official - Suffix:II
Authorized Official - Credentials:DMD
Authorized Official - Phone:802-862-8266
Mailing Address - Street 1:97 BLAKELY RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-4008
Mailing Address - Country:US
Mailing Address - Phone:802-862-8266
Mailing Address - Fax:802-862-6416
Practice Address - Street 1:97 BLAKELY RD
Practice Address - Street 2:SUITE 104
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-4008
Practice Address - Country:US
Practice Address - Phone:802-862-8266
Practice Address - Fax:802-862-6416
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRAFTON FAMILY DENTISTRY, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016-0002281261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1015584Medicaid