Provider Demographics
NPI:1518040955
Name:PINTO, AUDRA JEAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:AUDRA
Middle Name:JEAN
Last Name:PINTO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 KENNEDY DR
Mailing Address - Street 2:U6
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403
Mailing Address - Country:US
Mailing Address - Phone:802-862-6562
Mailing Address - Fax:
Practice Address - Street 1:1 KENNEDY DR
Practice Address - Street 2:U6
Practice Address - City:SO BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403
Practice Address - Country:US
Practice Address - Phone:802-862-6562
Practice Address - Fax:802-862-6565
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0160001236122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006507Medicaid
VT2466OtherBLUE CROSS BLUE SHIELD