Basic Information
| Provider Information | |||||||||
| NPI: | 1508825563 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | DENNIS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1346 | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054951346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025247100 | ||||||||
| FaxNumber: | 8025247021 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | SWANTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054881403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028683175 | ||||||||
| FaxNumber: | 8028682923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 055-0030446 | VT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1001761 | 05 | VT | MEDICAID |