Provider Demographics
NPI:1801459680
Name:NORTHEAST KINGDOM DENTAL GROUP PLLC
Entity type:Organization
Organization Name:NORTHEAST KINGDOM DENTAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:KRIETER
Authorized Official - Last Name:PIET
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:802-472-5005
Mailing Address - Street 1:PO BOX 555
Mailing Address - Street 2:
Mailing Address - City:HARDWICK
Mailing Address - State:VT
Mailing Address - Zip Code:05843-0555
Mailing Address - Country:US
Mailing Address - Phone:802-472-5005
Mailing Address - Fax:
Practice Address - Street 1:49 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:HARDWICK
Practice Address - State:VT
Practice Address - Zip Code:05843-6001
Practice Address - Country:US
Practice Address - Phone:802-472-5005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherDO NOT HAVE ANY OTHER IDENTIFIERS