Provider Demographics
NPI:1063786374
Name:WILLISTON ROAD FAMILY DENTAL , PLC
Entity type:Organization
Organization Name:WILLISTON ROAD FAMILY DENTAL , PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MELO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:802-863-0505
Mailing Address - Street 1:1340 WILLISTON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6469
Mailing Address - Country:US
Mailing Address - Phone:802-863-0505
Mailing Address - Fax:
Practice Address - Street 1:1340 WILLISTON RD
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6469
Practice Address - Country:US
Practice Address - Phone:802-863-0505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0160002103261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental