Provider Demographics
NPI:1831241215
Name:BRUCE C LATELLE & ALBERT ST.AMAND DDS PTR
Entity type:Organization
Organization Name:BRUCE C LATELLE & ALBERT ST.AMAND DDS PTR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCOTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:C
Authorized Official - Last Name:LATELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-878-1170
Mailing Address - Street 1:25 BISHOP AVE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7871
Mailing Address - Country:US
Mailing Address - Phone:802-878-1170
Mailing Address - Fax:802-879-7139
Practice Address - Street 1:25 BISHOP AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7871
Practice Address - Country:US
Practice Address - Phone:802-878-1170
Practice Address - Fax:802-879-7139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT5251223G0001X
VT5341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty