Provider Demographics
NPI:1851404271
Name:MIDDLEBURY DENTAL GROUP
Entity Type:Organization
Organization Name:MIDDLEBURY DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:RODERICK
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:802-388-3553
Mailing Address - Street 1:1330 EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-4425
Mailing Address - Country:US
Mailing Address - Phone:802-388-3553
Mailing Address - Fax:802-388-7377
Practice Address - Street 1:1330 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-4425
Practice Address - Country:US
Practice Address - Phone:802-388-3553
Practice Address - Fax:802-388-7377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty