Provider Demographics
NPI:1942384979
Name:DR. KENNETH J. STAVISKY, LTD.
Entity Type:Organization
Organization Name:DR. KENNETH J. STAVISKY, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:WHITCOMB
Authorized Official - Last Name:PHILBRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-865-1212
Mailing Address - Street 1:99 SWIFT ST
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7303
Mailing Address - Country:US
Mailing Address - Phone:802-865-1212
Mailing Address - Fax:802-865-4666
Practice Address - Street 1:99 SWIFT ST
Practice Address - Street 2:SUITE 115
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7303
Practice Address - Country:US
Practice Address - Phone:802-865-1212
Practice Address - Fax:802-865-4666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016000012421223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1962512038OtherINDIVIDUAL NPI