Provider Demographics
NPI:1891919924
Name:CHAMPLAIN DENTAL GROUP, LTD
Entity Type:Organization
Organization Name:CHAMPLAIN DENTAL GROUP, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:TEMPLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-863-5335
Mailing Address - Street 1:150 DORSET ST
Mailing Address - Street 2:SUITE 260
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6256
Mailing Address - Country:US
Mailing Address - Phone:802-863-5335
Mailing Address - Fax:802-863-9087
Practice Address - Street 1:150 DORSET ST
Practice Address - Street 2:SUITE 260
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6256
Practice Address - Country:US
Practice Address - Phone:802-863-5335
Practice Address - Fax:802-863-9087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1003294Medicaid