Basic Information
| Provider Information | |||||||||
| NPI: | 1538255864 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THORNTON | ||||||||
| FirstName: | BRENNAN | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 229 STONEHILL RD | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054959521 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 617 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028646309 | ||||||||
| FaxNumber: | 8026521087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 08/25/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 160000530 | VT | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 0001750 | 05 | VT | MEDICAID | 160000530 | 01 | VT | STATE LICENSE | OTHER |