Provider Demographics
NPI:1063699767
Name:VT CENTER FOR DENTAL IMPLANTS AND MAXILLOFACIAL SURGERY LLC
Entity type:Organization
Organization Name:VT CENTER FOR DENTAL IMPLANTS AND MAXILLOFACIAL SURGERY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DIKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-655-5090
Mailing Address - Street 1:792 COLLEGE PKWY STE 307
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-3052
Mailing Address - Country:US
Mailing Address - Phone:802-655-5090
Mailing Address - Fax:802-655-9366
Practice Address - Street 1:792 COLLEGE PKWY STE 307
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-3052
Practice Address - Country:US
Practice Address - Phone:802-655-5090
Practice Address - Fax:802-655-9366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016-00011231223S0112X
332B00000X
VT061-0001123261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1003069Medicaid
VTU01690Medicare UPIN
VTVT980801Medicare PIN