Provider Demographics
NPI:1962512038
Name:STAVISKY, KENNETH JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOSEPH
Last Name:STAVISKY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 SWIFT ST
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7324
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:05403-7324
Practice Address - Country:US
Practice Address - Phone:802-865-1212
Practice Address - Fax:802-865-4666
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0160001242122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
867774OtherTRICARE UNITED CONCORDIA