Provider Demographics
NPI:1508825563
Name:SMITH, DENNIS (PA-C)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
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 1346
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-1346
Mailing Address - Country:US
Mailing Address - Phone:802-524-7100
Mailing Address - Fax:802-524-7021
Practice Address - Street 1:12 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SWANTON
Practice Address - State:VT
Practice Address - Zip Code:05488-1403
Practice Address - Country:US
Practice Address - Phone:802-868-3175
Practice Address - Fax:802-868-2923
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030446207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1001761Medicaid
S83655Medicare UPIN
VT1001761Medicaid