Basic Information
| Provider Information | |||||||||
| NPI: | 1053460907 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE DENTAL CENTER AT COMMUNITY HEALTH CENTER OF BURLINGTON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 617 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028646309 | ||||||||
| FaxNumber: | 8028604324 | ||||||||
| Practice Location | |||||||||
| Address1: | 617 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028646309 | ||||||||
| FaxNumber: | 8028604324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 11/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | GREENOUGH | ||||||||
| AuthorizedOfficialFirstName: | DIANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8028646309 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 0001692 | 05 | VT | MEDICAID |