Basic Information
| Provider Information | |||||||||
| NPI: | 1386866366 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHERLY | ||||||||
| FirstName: | JITKA | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 749 | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056610749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028887585 | ||||||||
| FaxNumber: | 8028518313 | ||||||||
| Practice Location | |||||||||
| Address1: | 66 MORRISVILLE PLZ | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056614482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028887585 | ||||||||
| FaxNumber: | 8028518313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 09/23/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 13268 | MD | N | Dental Providers | Dentist | General Practice | 122300000X | 0160105895 | VT | Y | Dental Providers | Dentist |
No ID Information.