Provider Demographics
NPI:1023093606
Name:DINER, MURRAY
Entity type:Individual
Prefix:
First Name:MURRAY
Middle Name:
Last Name:DINER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 PROUTY DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855
Mailing Address - Country:US
Mailing Address - Phone:802-334-6965
Mailing Address - Fax:802-334-6606
Practice Address - Street 1:53 MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHFORD
Practice Address - State:VT
Practice Address - Zip Code:05476-1151
Practice Address - Country:US
Practice Address - Phone:802-848-3829
Practice Address - Fax:802-848-3849
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016.00020441223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006289Medicaid