Provider Demographics
NPI:1811404619
Name:GREEN MOUNTAIN DENTAL, PLC
Entity Type:Organization
Organization Name:GREEN MOUNTAIN DENTAL, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:ATEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:802-863-3950
Mailing Address - Street 1:118 TILLEY DR STE 101
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-4450
Mailing Address - Country:US
Mailing Address - Phone:802-863-3950
Mailing Address - Fax:802-863-6013
Practice Address - Street 1:118 TILLEY DR STE 101
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-4450
Practice Address - Country:US
Practice Address - Phone:802-863-3950
Practice Address - Fax:802-863-6013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty