Provider Demographics
NPI:1780886036
Name:GREEN MOUNTAIN ORAL SURGERY LLC
Entity type:Organization
Organization Name:GREEN MOUNTAIN ORAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERILYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:STOFKA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:802-775-9700
Mailing Address - Street 1:66 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-3249
Mailing Address - Country:US
Mailing Address - Phone:802-775-9700
Mailing Address - Fax:802-775-3237
Practice Address - Street 1:66 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-3249
Practice Address - Country:US
Practice Address - Phone:802-775-9700
Practice Address - Fax:802-775-3237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT01600020761223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006523Medicaid
VTVN26523Medicare ID - Type Unspecified
VT1006523Medicaid