Provider Demographics
NPI:1104465657
Name:VT CENTER FOR DENTAL IMPLANTS AND MAXILLOFACIAL SURGERY LLC
Entity type:Organization
Organization Name:VT CENTER FOR DENTAL IMPLANTS AND MAXILLOFACIAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:DESLAURIERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-655-5090
Mailing Address - Street 1:792 COLLEGE PKWY STE 307
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-3052
Mailing Address - Country:US
Mailing Address - Phone:802-655-5090
Mailing Address - Fax:800-524-4660
Practice Address - Street 1:1009 S MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:STOWE
Practice Address - State:VT
Practice Address - Zip Code:05672-5275
Practice Address - Country:US
Practice Address - Phone:802-253-2761
Practice Address - Fax:802-655-9366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-02
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies