Basic Information
| Provider Information | |||||||||
| NPI: | 1659766806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUDINGTON | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | WETERRINGS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 320 | ||||||||
| Address2: | |||||||||
| City: | PLAINFIELD | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056670320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024541047 | ||||||||
| FaxNumber: | 8023220714 | ||||||||
| Practice Location | |||||||||
| Address1: | 157 TOWNE AVE | ||||||||
| Address2: | |||||||||
| City: | PLAINFIELD | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056679425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024541047 | ||||||||
| FaxNumber: | 8023220714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2015 | ||||||||
| LastUpdateDate: | 04/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 04/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 016.0119165 | VT | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 1028057 | 05 | VT | MEDICAID |