Provider Demographics
NPI:1871822627
Name:SHELBURNE RESTORATIVE DENTISTRY
Entity Type:Organization
Organization Name:SHELBURNE RESTORATIVE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIPPE
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHARLEBOIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:802-985-9700
Mailing Address - Street 1:P.O. BOX 471
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-0471
Mailing Address - Country:US
Mailing Address - Phone:802-985-9700
Mailing Address - Fax:802-985-0134
Practice Address - Street 1:41 FALLS ROAD
Practice Address - Street 2:
Practice Address - City:SHELBURNE
Practice Address - State:VT
Practice Address - Zip Code:05482-0471
Practice Address - Country:US
Practice Address - Phone:802-985-9700
Practice Address - Fax:802-985-0134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-08
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016.00022911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty