Provider Demographics
NPI:1194738088
Name:FIDDLEHEAD FAMILY DENTISTRY PC
Entity type:Organization
Organization Name:FIDDLEHEAD FAMILY DENTISTRY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ULRICH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:802-527-7796
Mailing Address - Street 1:39 CONGRESS STREET
Mailing Address - Street 2:
Mailing Address - City:ST ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-1610
Mailing Address - Country:US
Mailing Address - Phone:802-524-9774
Mailing Address - Fax:802-524-9789
Practice Address - Street 1:39 CONGRESS STREET
Practice Address - Street 2:
Practice Address - City:ST ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-1610
Practice Address - Country:US
Practice Address - Phone:802-524-9774
Practice Address - Fax:802-524-9789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT01600010601223G0001X
VT01600010741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010490Medicaid