Provider Demographics
NPI:1881629632
Name:KOLODZEJ, ROBERT STEPHEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:STEPHEN
Last Name:KOLODZEJ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 GENERAL WING RD
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4682
Mailing Address - Country:US
Mailing Address - Phone:802-775-0819
Mailing Address - Fax:802-775-1487
Practice Address - Street 1:4 GENERAL WING RD
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4682
Practice Address - Country:US
Practice Address - Phone:802-775-0819
Practice Address - Fax:802-775-1487
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT769122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0002398Medicaid