Provider Demographics
NPI:1568794295
Name:WEST RIVER FAMILY DENTAL
Entity Type:Organization
Organization Name:WEST RIVER FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:VERNON
Authorized Official - Last Name:REDISKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:802-365-4313
Mailing Address - Street 1:74 GRAFTON ROAD
Mailing Address - Street 2:PO BOX 262
Mailing Address - City:TOWNSHEND
Mailing Address - State:VT
Mailing Address - Zip Code:05353
Mailing Address - Country:US
Mailing Address - Phone:802-365-4313
Mailing Address - Fax:802-365-4313
Practice Address - Street 1:74 GRAFTON RD
Practice Address - Street 2:
Practice Address - City:TOWNSHEND
Practice Address - State:VT
Practice Address - Zip Code:05353-0262
Practice Address - Country:US
Practice Address - Phone:802-365-4313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT01600022261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1013633Medicaid