Provider Demographics
NPI:1831170943
Name:WOOLHOUSE, PETER MYLES
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:MYLES
Last Name:WOOLHOUSE
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:PETER
Other - Middle Name:MYLES
Other - Last Name:WOOLHOUSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:440 GREEN MOUNTAIN ROAD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:VT
Mailing Address - Zip Code:05470
Mailing Address - Country:US
Mailing Address - Phone:514-932-5954
Mailing Address - Fax:514-932-1565
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:802-848-7554
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016-0002132122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008570Medicaid