Provider Demographics
NPI:1629324942
Name:WEST RIVER FAMILY DENTAL BRATTLEBORO
Entity Type:Organization
Organization Name:WEST RIVER FAMILY DENTAL BRATTLEBORO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
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:802-254-8322
Mailing Address - Street 1:36 PARK PL
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-2802
Mailing Address - Country:US
Mailing Address - Phone:802-254-8322
Mailing Address - Fax:802-258-9013
Practice Address - Street 1:36 PARK PL
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-2802
Practice Address - Country:US
Practice Address - Phone:802-254-8322
Practice Address - Fax:802-258-9013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016-0002226261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental