Provider Demographics
NPI:1558483321
Name:SOUTHERN VERMONT ENDONTICS, PC
Entity Type:Organization
Organization Name:SOUTHERN VERMONT ENDONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:LANG
Authorized Official - Last Name:ULLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:802-773-7767
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05702-0130
Mailing Address - Country:US
Mailing Address - Phone:802-773-9715
Mailing Address - Fax:802-775-7667
Practice Address - Street 1:71 ALLEN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4570
Practice Address - Country:US
Practice Address - Phone:802-773-7767
Practice Address - Fax:802-775-7667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT11241223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009354Medicaid