Provider Demographics
NPI:1932283488
Name:DUCHAM, RONALD E (DDS)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:E
Last Name:DUCHAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 PORTLAND ST
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-2054
Mailing Address - Country:US
Mailing Address - Phone:802-748-4727
Mailing Address - Fax:802-748-8490
Practice Address - Street 1:501 PORTLAND ST
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-2054
Practice Address - Country:US
Practice Address - Phone:802-748-4727
Practice Address - Fax:802-748-8490
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT4181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0001385Medicaid