Provider Demographics
NPI:1750568101
Name:ORAL CARE DENTAL GROUP
Entity type:Organization
Organization Name:ORAL CARE DENTAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTA MARIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-893-4734
Mailing Address - Street 1:157 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:VT
Mailing Address - Zip Code:05468-3607
Mailing Address - Country:US
Mailing Address - Phone:802-893-4734
Mailing Address - Fax:802-893-1406
Practice Address - Street 1:157 RIVER ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:VT
Practice Address - Zip Code:05468-3607
Practice Address - Country:US
Practice Address - Phone:802-893-4734
Practice Address - Fax:802-893-1406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT01600022131223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0001886Medicaid
VT1009136Medicaid
VT1012294Medicaid