Provider Demographics
NPI:1861690075
Name:PAUL G. BOERMAN, PC
Entity Type:Organization
Organization Name:PAUL G. BOERMAN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:G
Authorized Official - Last Name:BOERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:802-860-6725
Mailing Address - Street 1:44 TIMBER LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7204
Mailing Address - Country:US
Mailing Address - Phone:802-860-6725
Mailing Address - Fax:802-864-0277
Practice Address - Street 1:44 TIMBER LN
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7204
Practice Address - Country:US
Practice Address - Phone:802-860-6725
Practice Address - Fax:802-864-0277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0160000990261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0009446Medicaid
VT9446Medicare PIN
VT0009446Medicaid